Registration Form

Child Liability Form

Step 1 of 2

*Submitting a waiver does not guarantee a space in class. The office must be contacted to secure spaces in programs.

Family Information

Address

Emergency Medical Authorization

Should it become necessary for my child or ward to have emergency medical treatment while participating in activities associated or affliated with Break the Barriers, Inc. (Hereafter "BTB") I hereby authorize BTB personnel to use their jugdment in obtaining emergency medical services. I further authorize any individual selected by BTB personnel to render such emergency medical treatment to my child or ward as deemed necessary and appropriate. I understand that BTB is not responsible for paying the medical or hospital costs incurred on behalf of child or ward. Consequently, I understand and agree that all such costs shall be my sole responsibility.
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