Phoenix Center Participant Form (MFISD 2026-2027)

Phoenix Center Participant Form School Year 2026 - 2027 

Please answer ALL questions below which are needed for grant funding to ensure Phoenix Center programs remain free of cost for MFISD students. Thank you.

I have read, understand, and agree to the below:

1. I give permission for my child to participate in Phoenix Center programs and communicate with MFISD staff to coordinate support and services for my child. The services may include but are not limited to supportive guidance/counseling, groups, equine, or yoga programs. My child may complete voluntary surveys regarding experiences in Phoenix Center Programs.
2. I give permission for my child to participate in field trips and other programs sponsored by Phoenix Center. School or private transportation may be used in these and other activities.
3. I give permission for routine or emergency medical or dental treatment by any licensed medical doctor to be provided in the event of illness or accident if I am unable to be reached.
4.  I understand that participation has risks and if there is a medical, health, or other reason that my student should not participate in Phoenix Center programs, I will communicate that to Phoenix Center and MFISD staff before the program begins to restrict any activities and participation necessary for safety or health reasons.
5. I acknowledge that this consent is voluntary and may be revoked at any time by informing Phoenix Center staff, in writing, except that prior consent will still apply to the extent that agencies have already acted in reliance of it.
6.  I understand that computers, unencrypted email, text, e-fax communication can be accessed by unauthorized people which can compromise the privacy and confidentiality of such communication. If a client needs to contact a Phoenix Center staff, please do so on the Phoenix Center office phone line. They will respond to you within 24 hours during normal business hours. Please do not call Phoenix Center staff for emergencies; please call 911.
7.  I understand that if I have any ethical concerns, I can discuss them with the Phoenix Center staff, or file a complaint against the staff at the following organization: Complaints Management and Investigate Section P.O. Box 141369, Austin, Texas 78714 or 1 (800) 942-5540.
8. I release Phoenix Center and its employees, volunteers, or agents from liability for accidents, injuries, or illnesses that may occur to my child during his/her participation in the program. My child and I understand that we are voluntarily participating in the Phoenix Center program and can withdraw our consent in writing at any time.
9.  I understand that the data and information collected on my child is maintained in a secure computer database and a case file protected by the Health Insurance Privacy and Portability and Accountability Act. This information is used by the Phoenix Center to document services provided to students and families for tracking and reporting purposes. I also understand that the Phoenix Center may use the information to update service information, provide closure and follow-up information, and evaluate and determine the effectiveness of the program. I authorize Phoenix Center to maintain the information provided for the purposes noted above in the Phoenix Center secure computer database.
10.  I acknowledge that I have been given an opportunity to read a copy of the Phoenix Center’s Notice of Privacy Practices in accordance to the Health Insurance Portability and Accountability Act. A copy of the Notice of Privacy Practices can be found on the Phoenix Center’s website (www.phoenixtx.org) or a copy can be requested from the Phoenix Center. I understand that if I have questions regarding the Notice or my privacy rights, I can email info@phoenixtx.org or call (830) 637-7848.

My signature below authorizes Phoenix Center to provide programs and services for my child, to share information and communicate with MFISD, and releases and authorizes Phoenix Center to obtain information from MFISD. I have read, understand, and consent to all the above. By signing below, I consent and give permission for my child to participate in Phoenix Center programs. 

Does the parent who signed this form have legal custody of the child (legal parent or guardian)? (You must check one answer) 

  Yes No * 

PARTICIPANT AGREEMENT & RELEASE
Including Acknowledgement and Assumption of Risks and Agreements of Release and Indemnity  

I, the participant, or the parent or legal guardian (either, “Parent”) of the participant, if the participant is a minor (under eighteen years of age), for and in consideration of the services of Phoenix Center/Camp Phoenix acknowledge and agree as follows: 

1. Activities and Risks:  Phoenix Center/Camp Phoenix program services (both, referred to as “program” in this agreement) involve a variety of activities including warmups, discussions/debriefings, games, group initiatives (physically and cognitively), therapeutic activities, and moving on, around, and over high and low challenge ropes course elements, zip lines, aerial static ropes courses, and other structures at heights ranging from six inches to fifty feet or more.  The level of participation is always entirely voluntary and a matter of individual choice and for all aspects of the program. Management of risks is an important priority in the facilitation of all levels of programming, however accidents do occur. Risks include risks associated with motor vehicle travel, both to and from program sites and to the site of medical care; all elements of nature, falls, heat stroke, heat exhaustion and lightening; communicable diseases; all diseases associated with exposure to insects, reptiles and animals; errors in judgment, by youth, volunteers, staff, or any contract employee of Phoenix Center/Camp Phoenix; and all other risks associated with all Phoenix Center/Camp Phoenix programs and activities.  Participants may incur cuts, fractures, insect and reptile bites, and trauma from falls or contact with persons, animals (such as horses) or objects; heat and cold from exposure to natural elements, emotional upset or psychological stress, injury, fatigue; and in rare cases, death, including death while in a motor vehicle.  Participants may also experience other risks that may or may not be anticipated by participants and staff. These risks are inherent in Phoenix Center/Camp Phoenix programming and in moving about the facilities where these activities are offered - that is, without such risks the program would lose its value and appeal. 
2.  Medical Issues & Costs:  Phoenix Center/Camp Phoenix program activities are designed to be physically and emotionally demanding, for participants of average mobility and strength who are in reasonably good health. Certain medical conditions may increase the inherent risks of the experience and cause participants to be a danger to themselves or others. These potentially dangerous conditions include obesity, high blood pressure, cardiac and coronary artery disease, pulmonary problems, pregnancy, arthritis, tendonitis, or other joint and muscular-skeletal problems, seizure disorders, asthma, allergies, diabetes, impaired balance, eyesight, or hearing, and other physical, psychological and psychiatric disorders or other health conditions.  Participants, including Parent/Guardian if the participant is a minor, must carefully consider these issues before choosing to participate, and fully inform Phoenix Center/Camp Phoenix staff of any potentially dangerous condition prior to participating in the program’s activities. By accepting a participant with a disclosed condition, Phoenix Center/Camp Phoenix is NOT representing that it can, or will, successfully manage an event arising out of that condition.  Unless notified otherwise in writing, Phoenix Center/Camp Phoenix will assume that the participant is physically and emotionally capable of participating in all program activities without being a danger to themselves or others. Participants, or Parent/Guardian, understands they are solely responsible for any medical services that Camp Phoenix cannot accommodate. Participant (or their Parent/Guardian) is responsible for the cost of any necessary emergency transportation or medical service for the participant.
3.  Acknowledgment and Assumption of Risks:  I have been informed of and understand the nature of the program offered by Phoenix Center/Camp Phoenix - and its inherent and other risks - and that participation is entirely voluntary. I acknowledge and assume ALL the risks of being enrolled in and participating in the program.  If I am signing this document as a Parent, I have discussed the activities and their risks with my child who understands and wishes to participate, nevertheless. Please notify the Phoenix Center in writing (24 hours in advance of the program date) if there are any specific activities in which the participant can NOT participate.    Release and Indemnity:  I, an adult participant, or Parent of a minor participant (if Parent, for myself and, to the extent allowed by law, on behalf of the minor), hereby agree to release and indemnify (that is, defend and pay or reimburse) Phoenix Center/Camp Phoenix, its owners, officers, directors, employees, volunteers and agents  (the “Released Parties”) with respect to any and all claims, of whatever nature, including for property damage and personal injury, emotional trauma and death, which I or my minor child might incur or cause while enrolled or participating in a program of Phoenix Center/Camp Phoenix. This agreement of indemnity includes claims of members of my, or the child’s, family for losses suffered by me or the child; and claims of third parties, including co-participants, for any injury or loss claimed to be caused in whole or part by me or the child. These agreements of release and indemnity include claims arising in whole or in part from the negligence (but not the gross negligence) of a Released Party. These agreements of release and indemnity include, but are not limited to, claims based in whole or part on the NEGLIGENCE of a Released Party and extend to all costs and attorney’s fees incurred by Camp Phoenix / Phoenix Center.
   WARNING 
   UNDER TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES CODE), A FARM ANIMAL PROFESSIONAL OR FARM OWNER OR LESSEE IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN FARM ANIMAL ACTIVITIES, INCLUDING AN EMPLOYEE OR INDEPENDENT CONTRACTOR, RESULTING FROM THE INHERENT RISKS OF FARM ANIMAL ACTIVITIES.  
4.  Medical Care:  In the event of a medical emergency, Phoenix Center/Camp Phoenix is authorized to provide or obtain such medical care for the participant (minor child or myself), as it deems necessary, at my expense.
5.  Photo Release:  Participant, for him/herself and on behalf of a child, gives permission and consents to the taking of video, photographs, or interviews, and agrees that Camp Phoenix may use such photographs and video in promotional materials produced by Camp Phoenix/Phoenix Center in the future. (You must check a box.)   Yes  No * 
   Initial Here 

Phoenix Center/Camp Phoenix reserves the right to exclude anyone from participation, for medical, safety, or other reasons it deems appropriate. I acknowledge that I have been given the opportunity to ask questions regarding any aspect of this agreement, and by signing below I acknowledge that I have read completely and fully understand all aspects of this agreement and agree to its terms. This agreement, including the agreements of release and indemnity, is intended by me to be binding, including on my or the minor child’s estate and heirs, to the fullest extent allowed by law. <g-bubble jsname="VCkuzd" jscontroller="QVaUhf" data-du="200" jsaction="R9S7w:VqIRre;"></g-bubble>