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INFORMED CONSENT AND RELEASE OF LIABILITY

To Be Completed For High Risk Activities

________________________________________________________________ (the “Activity”)

(Describe Activity)

To: The Board of Education of School District No. 36 (Surrey) and its officials, employees, teachers and

agents (collectively and individually, the “Board”)

STUDENT:

In consideration of the Board permitting me to participate in the Activity,

I ________________________________________________ (the “Student”) state as follows:

1. I have discussed with my parent(s)/guardian their expectations, and the Board’s expectations, of my

behaviour during the Activity.

2. I understand and agree to abide by the School’s Code of Conduct and any other rules that are set

out for this Activity.

3. I agree to cooperate with, and follow the directions given to me by, any of the Activity’s supervisors

for the entire duration of the Activity.

4. I have discussed with my parent(s)/guardian the significance of the declaration I am making by

signing below.

________________________________________________

________________

Student

Date

PARENT(S)/GUARDIAN:

I ______________________________________________ (the “Parent(s)/Guardian”) am the

parent(s)/guardian of the Student. In consideration of the Board permitting the Student to participate in

the Activity, I agree as follows:

1. I have read and understand the materials provided to me by the Board outlining the Activity and

agree the Activity is appropriate for the Student. I hereby give my consent for the Student to

participate in the Activity.

2. I represent to the Board that the Student is medically fit to participate in the Activity. I have informed

the Student not to participate further if he/she feels anything to be unsafe.

3. I hereby agree that I shall pay any and all financial obligations, loss or claims for compensation that

the Board may suffer or incur in any way as a result of the Student’s participation in the Activity.

4. I hereby waive any and all legal rights that I may have now or in the future and release from liability

and agree not to sue the Board for any loss or damage that I may suffer as a result of the Student’s

participation in the Activity.

5. I recognize releasing the Board from liability prevents me from claiming for money from the Board.

6. I represent that I have discussed with the Student my expectations, the Board’s expectations, and

the risks and consequences of injury. I accept and assume all these risks and the consequences

and freely choose to permit the Student to participate in the Activity regardless.

7. I hereby agree that it is my responsibility to arrange insurance to cover any loss or damage the

Student may suffer, or liability I may incur, as a result of the Student’s participation in the Activity.

___________________________

______________________

_________________

Parent(s)/Guardian

Date

Form: 11150.5, Revised: 2011-02-23, Reference: Regulation 8901.2

Informed Consent And Release Of Liability

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