Civicorps Corpsmember Academy Application Form With Cover Letter (Page 6 of 8) in pdf

CIVICORPS CORPSMEMBER ACADEMY

FIELD TRIP PERMISSION / WAIVER FORM

(to be carried on trips by the school representative)

Civicorps includes regularly scheduled field trips to enhance the classroom learning and provide time for

recreational activities. We encourage all applicants to participate. Without this form applicants will not be allowed

to ride in Civicorps vehicles.

I hereby give my consent for myself (or daughter/son/ward) __________________________________,

attending the Civicorps Corpsmember Academy to go with Civicorps staff on educational and

recreational outings.

In case of emergency please contact: __________________________________________________

Phone # home ___________________________ work ___________________________________

In case of injury, you are authorized to provide emergency medical treatment.

Restrictions / Allergies: _____________________________________________________________

Critical Medical Info: _______________________________________________________________

________________________________________________________________________________

Birthdate: ___________________

Male / Female

1. Release (Injury to myself or child or to my personal property): That I release the Civicorps, its Board of Directors,

Agents, Officials and Employees for an injury or death to myself, child or for property damage on behalf of myself

or my heirs or successors in interest arising from my participation in the event or activity described above which is

conducted by Civicorps or is a Civicorps sponsored event.

2. Hold Harmless (Injury to Others or Property): That I will indemnify and hold harmless Civicorps its Board of

Directors, Agents, Officials and Employees from any loss or liability (bodily injuries or death, and/or damage to

property, including the loss of use thereof) which results or is alleged to have resulted from my participation or my

child’s participation in the event or activity described above.

3. Assumption of risk: That I assume all risks involved in my or my child’s participation in the event or activity

described above and that I recognize that I am solely responsible for my decision to participate or let my child

participate in the event or activity and that the above release stated in paragraph 1 includes but is not limited

Civicorps or a sponsoring agency.

____________________________________________

Signature of Parent/Caring Adult (if applicant is under age 18)

____________________________________________

Signature of Applicant

_______________________

Date

Civicorps Corpsmember Academy Application Form With Cover Letter Page 6