Halo Beacon LLC Electronic Personal Record Consent and Release Form


I, ______________________________________ (Name), am of sound mind and judgment. I hereby render my express written consent to give, consent, and grant to Halo Beacon LLC, its employees, representatives, agents, assigns, successor, and any other 3rd parties on the behalf of Halo Beacon, the right of use of any and all text, information or material written or typed contained in the Electronic Personal Record.

I, hereby warrant and represent that I am the lawful legal owner of the information and/or I am the lawful legal parent, guardian or by some other legal capacity (appointmentship, Power-of-Attorney or otherwise) of the minor’s information that I have provided in the Electronic Personal Record. I hereby warrant and represent the information that I have provided in the Electronic Personal Record is true and accurate to the best of my knowledge and belief. I shall forever release, indemnify and hold harmless, Halo Beacon, its employees, representatives, agents, assigns, successor, and any other 3rd parties on the behalf of Halo Beacon from any and all actions, claims, demands, losses, and liability arising out of or related to the inaccuracy or falsehood of the information I have provided in the Electronic Personal Record and any misrepresentation of the above warranties and representation herein.

I understand, acknowledge and agree that the use of any and all information in whole or in part contained in the Electronic Personal Record will be disclosed to applicable 3rd parties for Halo Beacon’s sole intended purposes to render the contracted services I have subscribed to.

I and on behalf of my heirs, assigns, personal representatives, and next of kin, hereby release, and shall forever discharge, Halo Beacon, its employees, representatives, agents, assigns, successor, and any other 3rd parties on the behalf of Halo Beacon from pursuing any and all actions, claims, demands, losses, and liability arising out of or related to the use and disclosure of any and all text, information or material written or typed contained in the Electronic Personal Record, whether arising from negligence of Halo Beacon, to the fullest extent permitted by law.

I and on behalf of my heirs, assigns, personal representatives, and next of kin, shall indemnify and hold harmless, Halo Beacon, its employees, representatives, agents, assigns, successor, and any other 3rd parties on the behalf of Halo Beacon from any and all actions, claims, demands, losses, and liability arising out of or related to the use and disclosure of any and all text, information or material written or typed as contained in the Electronic Personal Record, whether arising from negligence of Halo Beacon, to the fullest extent permitted by law.

The effective date of my consent and my release of claims and liabilities shall commence on the date signed below and shall continue to be effective until termination of my subscribed services with Halo Beacon.

I HAVE READ THIS HALO BEACON ELECTRONIC PERSONAL RECORD CONSENT AND RELEASE FORM, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP MY RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT.


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Signature

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FOR PARENTS/GUARDIANS OF PARTICIPANT OF MINOR

This is to certify that I, as parent/guardian with legal responsibility for my minor child, do consent and agree to his/her release as provided above to Halo Beacon, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless Halo Beacon, its employees, representatives, agents, assigns, successor, and any other 3rd parties on the behalf of Halo Beacon from any and all liability incidents regarding my minor child’s text, information or material contained in the Electronic Personal Record as provided above, even if arising from the negligence of Halo Beacon, to the fullest extent permitted by law.


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Signature of Parent or Legal Guardian

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Date