CA State PTA Student Participation Waiver for Arroyo
Today's Date:
MM
/
DD
/
YYYY
Please complete one waiver for EACH CHILD for participation in any PTA sponsored events (includes but not limited to the school Variety Show, Daughter and Loved-One Dance, Son and Loved-one, Choir, Carnival, 5th Grade Finale) for the 2018-2019 school year (Families with multiple children will fill out a waiver for each child).
Student's Last Name *
Your answer
Student's First Name *
Your answer
Student's Date of Birth: *
MM
/
DD
/
YYYY
Student's Grade *
Student's Teacher *
As the parent(s) or guardian(s) assume all risks in connection with the participation of my child listed above in any and all of the PTA sponsored activities. *
Required
I attest and verify that my child is physically fit and able to participate in any PTA sponsored activities. *
Required
I acknowledge that it is my responsibility to understand any inherent risks associated with PTA sponsored activities and communicate those risks to my child. *
Required
I do hereby certify that to the best of my knowledge and belief the individual named above is in good health. In the event that I, or other parent/guardian, cannot be reached in an emergency, I hereby give permission to secure proper treatment for my child. I/we do hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgement of the attending physician, surgeon or dentist and performed by or under the supervision of the medical staff of the hospital or facility furnishing medical or dental services. It is further understood that the undersigned will assume full responsibility for any such action, including payment of costs. *
Required
Do the above listed minor have allergies, medicine reactions or unusual physical conditions which should be made known to a treating physician. *
Required
If YES to above questions, please describe the allergies, medicine reactions or unusual physical conditions which should be made known to a treating physician. *
Your answer
I as a parent(s) or guardian(s) of the minor, do hereby, for my child, myself, my heirs, executors and administrators, release and forever discharge an hold harmless the California State PTA, the local PTA and all officers, directors, employees, agents and volunteers of the organizations, acting officially or otherwise, from any and all claims, demands, actions or causes of action which in any way arise from the participation of my child in any PTA sponsored activities. *
Required
By signing below, I confirm that I have carefully read and fully understand its contents. I am aware that this is a release of liability and signed (electronically) it of my own free will. *
Your answer
Thank you! Go Mustangs!
Submit
Never submit passwords through Google Forms.
This form was created inside of Tustin Unified School District. Report Abuse - Terms of Service