Internet Addiction Recovery Program APPLICATION ... - HEAL
Internet Addiction Recovery Program APPLICATION ... - HEAL
Internet Addiction Recovery Program APPLICATION ... - HEAL
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<strong>Internet</strong> <strong>Addiction</strong> <strong>Recovery</strong> <strong>Program</strong><br />
PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK<br />
PARENT'S OR GUARDIAN'S ADDITIONAL INDEMNIFICATION<br />
(Must be completed for participants under the age of 18)<br />
In consideration of (print minor's name)______________________________________________ ("Minor") being<br />
permitted by RESTART to participate in its activities and to use its equipment and facilities, I further agree to indemnify<br />
and hold harmless RESTART from any and all Claims which are brought by, or on behalf of Minor, and which are in any<br />
way connected with such use or participation by Minor.<br />
Parent or Guardian: ______________________ Print Name: ______________________ Date:___________<br />
June 9, 2009<br />
Page | 22<br />
reSTART <strong>Internet</strong> <strong>Addiction</strong> <strong>Recovery</strong> <strong>Program</strong> | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189<br />
restart@netaddictionrecovery.com | www.netaddictionrecovery.com
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