Consent And Release From Liability Certificate Template (Page 4 of 5) in pdf

should the need arise for such treatment while my/our child/ward is under the supervision of the

school or its employees, agents or representatives and I/We assume full responsibility for any

cost or medical expense incurred for the rendition of said medical treatment. I/We hereby certify

that my/our child/ward is healthy, and sufficiently physically fit and able to participate in this

activity and that I/We know of no fact to the contrary which would limit his/her participation. If

my/our child/ward has any physical condition which might limit his/her activity or cause my/our

child/ward to become ill it is listed below. I/We agree to inform the appropriate school officials

should my/our child’s/ward’s condition change in any way and at any time so as to affect his/her

participation in the activity named herein.

****I UNDERSTAND THAT THIS DOCUMENT CONTAINS A RELEASE****

_________________________________

______________________________

Signature of Student

Witness

_________________________________

______________________________

Print Name of Student

Print Name of Witness

_________________________________

______________________________

Date Signed

_________________________________

______________________________

Signature of Parent/Guardian

Witness

_________________________________

______________________________

Print Name of Parent/Guardian

Print Name of Witness

_________________________________

______________________________

Date Signed

_________________________________

______________________________

Home Address

Home and Emergency Phone #s

IMPORTANT: IF THE CHILD HAS ANY PHYSICAL CONDITION LIST IT HERE!

This medical information is included to assist the Activity Director/Teacher in assuring your

child’s/ward’s well being. Please list any known allergic reactions (bees, ants, medications,

substances, foods, etc.). List any medical conditions such as, but not limited to, asthma,

wheezing, heart disease, seizures, diabetes, muscular or skeletal problems or any other medical

condition or problem which you would like to bring to the schools attention. Please feel free to

call the school in advance of the activity date to discuss any concerns or specific health

problems.

______________________________________________________________________________

Form B

Consent And Release From Liability Certificate Template Page 4

Related Articles

Related forms

Related Categories