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8110 Gatehouse Road, Falls Church, VA 22042

Healthy Plate Club – Parental Release Form

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Thank you for your interest in Inova's Healthy Plate Club activities.  Parents: Please read the following information and fill out the form below.

Participant T-Shirt Size (T-shirts are sometimes given as prizes)
Address
Phone Number
Can we text you class updates and reminders?
Select Your Cell Phone Carrier
Photos for Marketing Purposes (See number 9 below)

Release, Waiver of Liability, and Media Authorization Form For Participation in Nutritional/Physical Activity Program

I, the undersigned, desire to give permission for myself or the above-named child (of whom I certify that I am a parent or legal guardian) (“Child”) to participate in a nutritional/physical activity program sponsored by Inova Health System Foundation and/or a subsidiary thereof (collectively “Inova”) at the location identified above.

I understand and agree as follows:

  1. I know of no reason, medical or otherwise, that would prevent Child/me from participating in this activity.
  2. I understand that the program does not screen for food allergies or medication interactions (for example, some cholesterol medications suggest that patients do not eat grapefruit while on the medication), and that I am responsible for screening the food I am provided and following up with my physician or pharmacist if I have any questions about allergies or medication interactions. I understand and agree that Inova is gratuitously providing the fruits, vegetables, and other food items and that Inova does not assume responsibility for the use and consumption of such food. I will be responsible for the handling, storage, and use of the food after receipt.
  3. I understand that fruits and vegetables can be contaminated during the growing process and carry the risk of foodborne illness. In order to reduce the risk of contamination, I understand the following recommendations should be followed for food handling and storage:
    • Wash your hands for 20 seconds with warm water and soap before and after preparing fresh produce.
    • If damage or bruising occurs before eating or handling, cut away the damaged or bruised areas before preparing or eating.
    • Rinse produce BEFORE you peel it, so dirt and bacteria aren't transferred from the knife onto the fruit or vegetable.
    • Gently rub produce while holding under plain running water.
    • Use a clean vegetable brush to scrub firm produce, such as melons and cucumbers.
    • Dry produce with a clean cloth or paper towel to further reduce bacteria that may be present.
    • Remove the outermost leaves of a head of lettuce or cabbage.
    • Store perishable produce in the refrigerator at or below 40 degrees
  4. I assume all risks of Child’s/my participation in this activity and full responsibility for Child’s/my conduct and actions, including any injury to myself, Child or others or damage to property that may result from Child’s/my participation, and I understand the Inova is not responsible for conditions created by other participants or by the location. I assume any and all risks of consumption of food items provided by Inova.
  5. I authorize the program and its volunteers to administer pre- and post-surveys to get feedback from myself or my Child. I also authorize the program to release age/grade, gender, race/ethnicity and other basic information. I understand that such information will be used to demonstrate success of the program, and that individually identifiable information will not be shared publicly (as only de-identified, aggregated data will be shared publicly).
  6. I hereby release and hold harmless Inova, its trustees, officers, employees, and affiliates from any and all damages, claims, actions, liability and expenses (including costs of judgments, settlements, court costs, and attorney’s fees), regardless of the outcome of such claims or actions, arising out of or relating in any way to Child’s/my participation.
  7. I understand that Inova does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance, in the event of injury, illness, death or property damage.
  8. I expressly agree that this release is intended to be as broad and inclusive as permitted by the laws of the Commonwealth of Virginia, and that this release shall be governed by and interpreted in accordance with the laws of the Commonwealth of Virginia. I agree that in the event that any clause or provision of this release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this release which shall nonetheless remain in full force and effect.
  9. I hereby authorize Inova, its facilities, and their employees and authorized agents and representatives to take photographs, videos or other recordings related to Child’s/my participation, and I consent to the use of such photographs, videos or recordings by Inova in any publication, website, program, presentation or other media, now or in the future, without compensation for me, for the purpose of education, telemedicine, marketing, development, community affairs, public relations, news media or healthcare communications, or other stories that will be read, seen and/or heard by the public. I understand that Child/I has/have the right to cease participating in any recording, filming or photography session.

I have read and understand this form and have signed this voluntarily.