Medical Authorization Form (Page 2 of 2) in pdf

Archway C lassical A cademy -‐ T rivium

SECTION 2 – MEDICAL AUTHORIZATION

I/we, the undersigned parent(s) or legal guardian of the minor listed above, do herby authorize in an

emergent or non-emergent situation any administration of first aid, the use of an ambulance, x-ray examination,

anesthestic, dental, medical or surgical diagnosis or treatment by any physician or dentist licensed by the state of

Arizona and hospital service that may be rendered to said minor under the general, specific or special consent of the

temporary custodian of the minor, whether such diagnosis or treatment is rendered at the offices of the physician or

dentist to call in any necessary consultants, in his/her/their discretion.

It is understood that this consent is given in advance of any specific diagnosis or treatment being required,

but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to

exercise his/her/their best judgment as to the requirements of such diagnosis of medical, dental, or surgical

treatment.

SECTION 3 – ACCIDENT WAIVER & RELEASE OF LIABILITY

I/we, hereby assume all of the risks of participation, including by way of example and not limitation, any

risks that arise from negligence or carelessness on the part of the persons or entities being released, from dangerous

or defective equipment or property owned, maintained or controlled by them or because of their possible liability

without fault.

I certify that I am physically fit, had sufficiently prepared or trained for participation in the activity or

event, and have not been advised to not participate by a qualified medical professional. I certify that there are no

health-related reasons or problems which preclude my participation in this activity or event.

I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders,

sponsors, staff, and organizers of the activity or event in which I may participate, and that it will govern my actions

and responsibilities at said activity or event.

I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as

follows:

(A) I waive, release, and discharge from any and all liability, including but not limited to, liability arising from

the negligence or fault of the entities or persons released, for my death, disability, personal injury, property

damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to

and from this event.

(B) I indemnify hold harmless, and promise not to sue the entities or persons mentioned in this paragraph from

any and all liabilities or claims made as a result of participation in this activity or event.

directors/volunteers, the activity/event holders, activity/event sponsors, activity/event volunteers.

I acknowledge that this activity or event may involve a test of a person’s physical or mental limits and may carry

with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those

caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, actions of

other people, including but not limited to, participants, volunteers, spectators, event officials, etc.

SECTION 4 – PARENT/GUARDIAN AGREEMENT

The undersigned parent/legal guardian does herby represent that he/she is, in fact, acting in such capacity,

has consented to his/her child or ward’s participation in the activity or event, and has agreed individually on behalf

of the child/ward to the terms of the accident waiver, release of liability, and medical authorization set forth above.

I certify that I have read this document, and I fully understand its content. I am aware that this is

a release of liability/medical authorization and a contract and I sign it of my own free will.

Event Participation including, but not limited to: Field Trips

Sports Events Social Life Events Competitions

Club EventsBefore / After School Activities

______________________________________________________________

Parent/Guardian’s Signature ____________________________________ Date ____________

Printed Parent/Guardian’s Name __________________________________________________

Medical Authorization Form Page 2

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