**All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. **

I hereby certify that I am the adult parent or legal guardian of abovenamed, a minor child under the age of eighteen years, and I consent to their participation in the event , inspiHER, offered by Momentum Health & Wellness.

I understand and acknowledge that there may be inherent risks, hazards or dangers associated in participating in inspiHER event, any of which could result in my sustaining personal and/or bodily injury to my child. I agree that Momentum Health & Wellness shall not be liable or responsible for any injuries to my child, resulting from their participation in the event, inspiHER. I expressly release and discharge Momentum Health & Wellness, her company’s owners, employees, volunteers, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with their participation in the event, inspiHER. This Release shall be binding upon my heirs, executors, administrators and assigns.

I give full permission for any person connected with Momentum Health and Wellness to administer first aid deemed necessary for the child, and in case of serious illness or injury, I give permission to call for medical for the child and to transport the child to a medical facility deemed necessary for the well-being of the child. I represent and warrant that I have the authority to give such permission in respect of the Minor. I AM the legal guardian and/ or parent of abovenamed and have read the foregoing and fully understand the contents thereof. THIS CONSENT and RELEASE is granted to Momentum Health and Wellness in perpetuity.

I hereby grant Momentum Health and Wellness, its assigns, licensees and legal representatives the irrevocable right to use my name or the Minor's name/photograph/image/audio recording/video recording/ and likeness ("My Image") in all forms and manner including but not limited to publication on Internet Web Sites, broadcasts and any other publications as released to or by Momentum Health and Wellness. I understand that Momentum Health and Wellness cannot control unauthorized use of the Minor's Image by persons not associated with Momentum Health and Wellness once the Minor's Image has been published. I hereby forever waive any right to inspect or approve any publication of the Minor's Image by Momentum Health and Wellness.

I AM the legal guardian and/ or parent of abovenamed child and have read the foregoing and fully understand the contents thereof. THIS CONSENT and RELEASE is granted to Momentum Health and Wellness in perpetuity.