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Email / Correo electrónico*
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What race do you identify with? / ¿Con qué raza te identificas?*
Choose all that apply / (Elija todas las que correspondan)
Do you identify as Latino/a/e/x? / ¿Te identificas como latino / a / e / x?*
Please select any of the following services you're currently receiving:*
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Consent*
IN CONSIDERATION OF PARTICIPANT BEING ALLOWED TO PARTICIPATE IN THE REGISTERED CLASS(ES) OR PROGRAM(S), THE UNDERSIGNED HEREBY RELEASES HEALTHIER TEXAS, ITS EMPLOYEES AND AGENTS, FROM ANY ACTION, CLAIM OR DEMAND FOR PERSONAL INJURY OR PROPERTY LOSS ARISING FROM OR DUE TO ANY NEGLIGENT ACT OR OMISSION OF IT’S TIME TEXAS, ITS AGENTS OR EMPLOYEES. THIS RELEASE SHALL HAVE NO EFFECT WITH REGARD TO DAMAGES CAUSED BY HEALTHIER TEXAS’ GROSS NEGLIGENCE. IN THE EVENT HEALTHIER TEXAS OR A VOLUNTEER PROVIDES TRANSPORTATION FOR THE REGISTERED PARTICIPANT, THIS WAIVER AND RELEASE SHALL EXTEND TO AND RELEASE HEALTHIER TEXAS EMPLOYEE DRIVER FROM ANY AND ALL LIABILITY. PERMISSION IS GIVEN FOR ANY EMERGENCY MEDICAL TREATMENT, OPERATION OR ANESTHESIA WHICH MIGHT BECOME NECESSARY. I AGREE TO BE RESPONSIBLE FOR THE EXPENSE OF MEDICAL TREATMENT OR SERVICE.

EN CONSIDERACIÓN DE QUE SE PERMITA A LOS PARTICIPANTES PARTICIPAR EN LAS CLASES O PROGRAMAS REGISTRADOS, EL ABAJO FIRMANTE LIBERA HEALTHIER TEXAS, SUS EMPLEADOS Y AGENTES, DE CUALQUIER ACCIÓN, RECLAMO O DEMANDA POR LESIONES PERSONALES O PÉRDIDA DE PROPIEDAD QUE SURJA DE O DEBIDO A CUALQUIER ACTO NEGLIGENTE U OMISIÓN DE HEALTHIER TEXAS, SUS AGENTES O EMPLEADOS. ESTE LANZAMIENTO NO TENDRÁ NINGÚN EFECTO CON RESPECTO A LOS DAÑOS CAUSADOS POR LA NEGLIGENCIA GRAVE DE HEALTHIER TEXAS. EN CASO DE QUE HEALTHIER TEXAS O UN VOLUNTARIO BRINDE TRANSPORTE PARA EL PARTICIPANTE REGISTRADO, ESTA EXENCIÓN Y EXENCIÓN SE EXTENDERÁ Y LIBERARÁ AL CONDUCTOR DEL EMPLEADO DE HEALTHIER TEXAS DE TODA RESPONSABILIDAD. SE OTORGA PERMISO PARA CUALQUIER TRATAMIENTO MÉDICO DE EMERGENCIA, OPERACIÓN O ANESTESIA QUE PUEDA SER NECESARIA. ACEPTO SER RESPONSABLE DEL GASTO DEL TRATAMIENTO O SERVICIO MÉDICO.

FOR EMERGENCY USE / PARA USO DE EMERGENCIA

Emergency Contact Information / Información del Contacto de Emergencia
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Emergency Contact Name / Contacto de Emergencia Nombre*
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