For rising 4th-6th graders.

We (or I) hereby request that you accept the application for the Veritas Discovery Program at St. Agnes Academy on the dates set forth. In consideration of your acceptance of this application, we (or I) hereby release St. Agnes Academy and all its employees and agents from all claims on account of any injuries which may be sustained by our (or my) child while attending the St. Agnes Middle School Summer Program, and its employees and agents for any claim which may be hereafter presented by our (or my) minor child. We (or I) know of no mental or physical problems which may affect our (or my) child's ability to safely participate in the program. I further certify that the above mentioned person has insurance in case of emergency. Additionally, I consent to any medical treatment deemed necessary by the Summer Program Director in the event of illness or injury to my child or dependent.