This health history is true to the best of my knowledge. The person herein described has my permission to engage in all prescribed activities except as noted above. The following authorization empowers Xi Omega/Bridge Builders to take whatever steps they deem necessary to insure the well-being of my child should a medical emergency occur.*

My child is in good physical health and does not have any disabilities which may be aggravated except as noted on this form. I release Xi Omega/Bridge Builders and its members from all liability. In the event that I cannot be reached in an emergency, I hereby the authorize Bridge Builders to secure proper treatment for my child in the case of emergency.*

I hereby grant permission for my child to participate in activities arranged by Xi Omega/Bridge Builders. By signing below, I release Xi Omega/Bridge Builder and all of its affiliates and volunteers from liability in case of accident, injury, or loss resulting from all causes in connection with such participation including outings, field trips, and/ or other activities. *

In granting this permission and release, I specifically recognize that my child may be transported to events by private vehicles operated by advisors or Bridge Builder. I understand the inherent risk of my child riding in an automobile. I specifically release and will hold the driver, Xi Omega and Bridge Builder their officers, members, etc. harmless for any negligence, accidents, or damages, regardless of fault. *

Any disputes or legal claims arising from any activities or transportation will be settled or resolved by binding arbitration and according to the rules of the American Arbitration Association.*