Athletic Competition Health Screening Form (Page 3 of 3) in pdf

CALAVERAS UNIFIED SCHOOL DISTRICT

MEDICAL TREATMENT AUTHORIZATION

WAIVER, RELEASE AND INDEMNITY AGREEMENT

ASSUMPTION OF RISK FOR PARTICIPATION IN VOLUNTARY SPORTS PROGRAM

Participant:_________________________________________________________________________________

Name of School:

Activity:

______________

By my signature below, I hereby give permission for my son/daughter to participate in the above described activity. I realize

that sport activities are voluntary as part of the Calaveras Unified School District school sports program. I understand that

participation in sport activities could cause serious illness and/or injury or death, and I assume all risks for any such illness and/or

injury or death. I am aware that the District assumes no responsibility for any transportation arrangements and no District coverage

for medical treatment is provided in connection with sport activities. If a participant does not have private medical insurance, low-cost

school insurance is available through the District.

For and in consideration of permitting the above named child to participant in school sport activities, the undersigned hereby

voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for personal injury, bodily injury,

property damage or wrongful death occurring to him/herself arising in any way whatsoever as a result of engaging in said activity or

any activities incidental thereto wherever or however the same may occur and for whatever period said activities may continue. The

undersigned does for him/herself, his/her heirs, executors, administrators and assigns hereby release, waive discharge and relinquish

any action or causes of action, aforesaid, which may hereafter arise for him/herself and for his/her estate, and agrees that under no

circumstances will he/she or his/her heirs, executors, administrators and assigns prosecute, present any claim for personal injury,

bodily injury, property damage or wrongful death against the District or any of its officers, agents, servants, or employees for any of

said causes of action, whether the same shall arise by the negligence of any of said persons, or otherwise.

The undersigned hereby acknowledges that he/she has been advised of all rules and safety regulations pertaining to sport activities and

the use of protective equipment by all participants. I understand these safety regulations will be enforced during all games and

practices. I fully understand that participants are to abide by all rules and regulations governing conduct during sport activities.

As provided for in California Education Code, Section 35330, I agree to waive all claims against the Calaveras Unified School

District. I, the undersigned hereby acknowledges that he/she knowingly and voluntarily assumes all risks of bodily injury

and/or death to his/her child, as stated, and expressly acknowledges their intention, by executing this instrument, to exempt

and relieve the District, its officers, agents, and employees, from any liability for personal injury, bodily injury, property

damage or wrongful death that may arise out of or in any way be connected with the above-described activity. I have read the

foregoing and have voluntarily signed this agreement. I am aware of the potential risks involved in sport activities and I am

fully aware of the legal consequences of signing this instrument.

Health or special needs:

Check as appropriate.

Participant has no special health needs the staff should be aware of, and no medication is required.

____

Participant has a special need. Explain: ___________________________________________________________

_____

__________________________________________________________________________________________

In the event of illness or injury, I do hereby consent to whatever x-ray examination, anesthetic, medical, surgical or dental diagnosis,

treatment, emergency transportation, and hospital care considered necessary in the best judgment of the attending physician, surgeon,

or dentist and performed under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental

services. This form must be signed before student can participate.

_______________________________________________

________________________________________________

Parent/Guardian Signature

Student Signature

_______________________________________________

___/___/20___ __________________________________

Parent/Guardian Name (Please Print)

Date

Phone Number (home)

(work)

________________________________________________

__________________________________________________

Street Address

City

State

Zip Code

Athletic Competition Health Screening Form Page 3

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