AUTHORIZATION TO TREAT A MINOR
I, the parent or legal guardian, of the child listed above, do hereby authorize and consent to any X-ray examination, anesthetic, medical, or surgical treatment rendered under the general or special supervision of
any member of the medical staff and emergency room staff licensed under the provisions of the Medical
Practice Act or a Dentist licensed under the provisions of the Dental Practice Act and on the staff of any
acute general hospital or emergency care facility holding a current license to operate a hospital or emergency
care facility from the Beaufort County Department of Public Health. I understand that this authorization is
given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide
authority and power to render care which the aforementioned physician, in the exercise of his/her best
judgment, may deem advisable for my child. Further, I understand my child could be participating in
inherently dangerous activities and agree to pay for my child’s medical expenses. I understand that all efforts
shall be made to contact me prior to rendering treatment to my child, but any of the above treatment will not
be withheld if I cannot be reached. This authorization is given pursuant to the provisions of the Beaufort
County Civil Code.
RELEASE FROM LIABILITY
It is understood that my child will be participating in after-school and/or summer camp activities and taking
field trips coordinated by the Inner Banks STEM Center (IBX STEM), in collaboration with other authorized
organizations, partners, agencies, or governmental entities in our STEM program. These activities will
include participation in science, technology, engineering and math activities that could include flying in an
airplane, RC model airplanes/drones, rocketry, robotics, CAD orientation, hands-on classroom projects, and
water related activities such as swimming, snorkeling, scuba diving and sailing. I and my child hereby agree
to assume all risks attendant upon myself and my child while participating in this program and/or related
sponsored activities. I and my child hereby waive, release, and discharge any and all claims for damages for
death, personal injury, or property damage which I or my child may have, or which may hereafter accrue to
me or my child, as a result of my child’s participation in this IBX STEM program or a sponsored activity. I
agree to indemnify and hold harmless from liability IBX STEM and any collaborating organizations,
partners, and/or any of their directors, officers, agents, staff, volunteers, or employees by reason of any
accident, death, injury, or damages, to persons or property which I or my child may suffer while participating
in a IBX STEM program and/or sponsored activity even though that liability may arise out of negligence or
carelessness on the part of the persons or entities mentioned above.
It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my
heirs and assigns, and the heirs and assigns of my child. I agree to assume all responsibility for any property
damage or injury to any person caused by me or my child while participating in any IBX STEM activity.
Waiver of Liability Relating to Coronavirus/COVID-19: IBX STEM has put in place preventative
measures to reduce the spread of COVID-19; however, IBX STEM cannot guarantee that you and/or your
child(ren) will not become infected with COVID-19. I am aware that my child/children must follow the
safety and hygiene protocols that have been implemented by IBX STEM at all times. No exceptions.
I understand the risk of becoming exposed to or infected by COVID-19 at IBX STEM may result from the
actions, omissions, or negligence of myself and/or others, including but not limited to, IBX STEM staff,
volunteers, participants, and their legal guardians while participating in an event conducted, organized,
and/or sponsored by IBX STEM. Such exposure or infection may result in personal injury, illness,
permanent disability, and death.
By submitting this form, I hereby release, covenant not to sue, discharge, and hold harmless IBX STEM, its staff,
instructors, volunteers, youth community service workers, contractors, and representatives of and from the
claims, including all liabilities, claims, actions, damages, or costs or expenses of any kind arising out of
authorized IBX STEM activities. This release includes any claims based on the actions, omissions, or
negligence of IBX STEM designated representatives, whether a COVID-19 infection occurs before, during,
or after participating in an event conducted, organized, and/or sponsored by IBX STEM.
In signing this form, I understand that my child/student participant:
- Can only be picked-up by the authorized parent/legal guardian unless prior written
arrangements are approved by IBX STEM personnel.
- Must be dropped-off/picked-up at the designated time and location (schedule).
- Must obey the IBX STEM program rules.
- Must PASS a safety swimming test to participate in the sailing school program.
- CAN BE VIDEOTAPED/PHOTOGRAPHED in IBX STEM activities/field trips
- Is liable for damage to drone, batteries, smartphone, or charger due to negligence.
I have read, understand, and approve all paragraphs and stipulations contained in this IBX STEM
participating application student. This application shall remain in effect for 12 calendar months from the signing date of this application. By submitting this form I agree to and authorize the terms and conditions outlined above.
