Authorization and Waiver to Transport Child

Valid: August 1, 2018  -August 30, 2018 Child’s

First Name: _____________________________ Child’s Last Name: _____________________________ Child’s Date of Birth: _________________

My child requires a booster seat:  Yes______No ______(All children under 8 years of age are required to be in a booster seat)

I authorize CD Hullinger Art Studio, Inc. to transport my minor child in a company Van, driven by an individual authorized by CD Hullinger Art Studio, Inc.______

I understand my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or staff or volunteer______.

I understand participation in the identified event is not a requirement for participation in the program.______

I have read, understand, and discussed with my child:

(1) My child will travel in a motor vehicle driven by an adult and my child is to wear their safety belt during travel ______

(2) My child is expected to listen to supervising staff/driver, respect staff and other children, the vehicles they ride in, and the people they travel with during the trip______

(3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers, or objects______

(4) My child is to remain in their seat and not be disruptive to the driver of the vehicle. Initial Each Statement _______

I recognize participation in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify I have been advised of the potential risks, and I have full knowledge of the risks involved in this activity, and I assume any expenses incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses. _______

As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge CD Hullinger Kids Art Studio, Inc., and their agents, officers, employees and volunteers from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. _______

I have read this entire waiver and authorization form, I fully understand its terms and conditions, and I agree to be legally bound by its terms. Parent/Guardian Name:


________________________________________________________________ _________________________ Parent/Guardian Signature    Date________

CD Hullinger Kids Art Studio, LLC

14456 Union Ave.

San Jose, CA 95124