Father's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact #1 *

First Name

Last Name

Emergency Contact #1 *

(###)

###

####

Emergency Contact #2 *

First Name

Last Name

Emergency Contact #2 *

(###)

###

####

Mother/Partner's Name *

Mother/Partner must have been a Finley mom prior.

First Name

Last Name

Child's Name *

First Name

Last Name

Child's Birth Date *

MM

DD

YYYY

Date of Loss *

MM

DD

YYYY

I understand that my support coordinator does not take the place of a professional mental health counselor and release, waive, and forever discharge The Finley Project®, its Board of Directors and its officers, agents and employees, from any and all liability, claims, demands, actions, or causes of actions arising out of or related to my participation in The Finley Project® program. In no event shall The Finley Project® be liable for any incidental, consequential, indirect, statutory, special, exemplary or punitive damages, including, but not limited to, lost profits, loss of use, loss of time, inconvenience, loss business opportunities, damage to goodwill or reputation, or other economic loss, regardless of whether such liability is based on breach of contract, tort, strict liability or otherwise, and even if advised of the possibility of such damages or such damages could have been reasonably foreseen. *

I agree

I shall indemnify, defend, and hold harmless The Finley Project®, its Board of Directors and its officers, agents and employees from any loss, liability, damage, or expense including reasonable attorneys’ fees and costs from any claim that may arise from or in connection with my participation in The Finley Project® program. If I fail to promptly indemnify and defend a covered claim, The Finley Project® shall have the right to defend itself, and in such case, I will promptly reimburse The Finley Project® for all of its associated costs and expenses. *

I agree

I represent that I am at least eighteen (18) years of age and am fully competent to sign this agreement. This agreement shall (i) be binding upon me and my agents, representatives, assigns, heirs, and successors in interest; (ii) be governed by and construed in accordance with the laws of the State of Florida without giving effect to any choice or conflict of law provision or rule; and (iii) any and all claims arising out of or relating to this agreement shall be brought in a state or federal court of competent jurisdiction in Orange County, Florida. I consent to the personal jurisdiction of the state and federal courts located in Orange County, Florida. I waive (a) any objection to jurisdiction or venue, or (b) any defense claiming lack of jurisdiction or improper venue, in any action brought in such courts. *

I agree

Form completed by: *

First Name

Last Name