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RELEASE OF LIABILITY

Home Based Services Release

THIS AGREEMENT is made on between EB Pediatric Resources, Inc. (“Provider”) and the person listed below (“Parent”) who is a natural parent of the Child or the legally appointed guardian of the Child concerning Therapeutic Play Interactions, Developmental Therapy or other home based services (“Services”) provided to the Child listed above.

Recitals
WHEREAS, Provider will be entering Parent’s home to provide Services and the Parent has retained Provider to render the Services to the Child. Provider has given Parent a full and adequate opportunity to ask questions and obtain a full and complete explanation of the risks of the activity;

PARENT’S RELEASE: This is the certify that I, on my own behalf and on behalf of my child, fully understand that there is risk of personal injury to my child in participating in play-based activities and other physically active games through the programs provided by EbPediatric Resources, Inc. d/b/a Therapeutic Play Interactions™. I am aware that my child is engaging in physically active games and/or therapeutic play-based activities which could result in his/her injury. I am voluntarily allowing my child to participate in these activities and assume all risks of injury that may result. I personally, and on behalf of my child, agree to hold no individual or corporation responsible or liable for any injuries that my child receives on account of these activities, including but not limited to EbPediatric Resources Inc, or its officers, employees, agents, aides, therapists, instructors, insurers, successors, or assigns (hereinafter “Releasees.”) I further agree to waive any claims or causes of action against and to hold harmless said Releasees for any injuries or damages which my child suffers or might suffer as a result of the conduct of any person during or in conjunction with said physically active games or therapeutic play-based activities. EbPediatric Resources Inc and its officers, employees, subcontractors, agents, therapists, aides, or instructors will make no formal evaluation whether my child is sufficiently fit for any exercise or activity. I agree that my child is able to participate in a therapeutic play-based physical activities program and that it will not be detrimental or inimical to his/her health, safety, comfort, or physical condition and that of others if he/she participates in said activities.

NOW, THEREFORE, in consideration of the Parent retaining Provider to provide Services to the Child in the Parent’s home, the parties agree that:

• Provider and its employees, independent contractors, agents, and representatives are fully released from all liability for all actions taken in providing the Services to the Child, including but not limited to damage to household goods.
• Parent or an adult selected by Parent shall be present during all times Services are provided.
• During the term Services are provided and for a period of 6 months thereafter, Parent will not offer to employ any employees or independent contractors of Provider without the prior, written consent of Provider and for a fee acceptable to both parties to fairly compensate Provider for the loss of any such employee or independent contractor and the cost of hiring another in his or her place.

EBPR Policies

Payment
Payments are due in full prior to or on the first day of service. EBPR accepts personal checks and money orders. Payment can be made via credit card online.

Cancellation Policy
Refunds are not given for missed appointments. If you cancel a session, it is possible to reschedule a make-up session based on provider availability and based on a minimum of 12-hour notice of cancellation.

Liability
EBPR is not responsibility for breakages or injuries caused within your home. It is the parent/guardian’s responsibility to attend sessions or make arrangements to have a designated caretaker present at all times during sessions.