Wilcox Senior Send-Off Reservation and Liability Waiver Form
Parents/Guardians, please complete the following. Only Wilcox Seniors with a completed reservation and liability waiver on file will be admitted to Wilcox Senior Send-Off 2018. Note: If you do not accept the terms below, you will not be able to complete the reservation. If you have questions, email Wilcoxsendoff@gmail.com

Parent, please provide your email below. A copy of your responses will be sent once your form has been submitted. We also suggest that you print a copy of your responses for your records before you click "Submit".

Email address *
Student Information
Please provide the name of the student that will be participating in the Wilcox Senior Send-Off 2018 event.
First Name *
Your answer
Last Name *
Your answer
Student ID *
Your answer
Student's Age *
If the participating student is under 18 by June 2, 2018, please list their age
Your answer
Email *
Student's email address
Your answer
Emergency Name and Cell Phone *
In case of emergency, please provide a contact and phone number where we can reach a parent or guardian.
Your answer
Pajama Pants
Pants are no longer available. Deadline passed. Each participant will receive a pair of Wilcox pajamas pants for reservations that were received by 5/9. Pants only come in adult sizes. Please select size below:
Pant Size
Senior Send-Off 2018 Student Participation Approval and Waiver of Liability , Indemnity, and Behavior Agreement
I/We the parent(s)/guardian(s) of the listed individual above, a student at Adrian C. Wilcox High School, hereby grant permission for the aforementioned student to participate in the Wilcox Senior Send-Off 2018 at Adrian C. Wilcox High School in Santa Clara on June 2, 2018 beginning at 8:45pm and ending at 1:00am on June 3, 2018. I/We further agree to defend, indemnify, and hold harmless the Santa Clara Unified School District, its Board of Trustees, officers, agents and employees; the Adrian C Wilcox High School PTSA, their officers, agents and the Adrian C. Wilcox High Senior Send-Off committee, its members and volunteers individually and collectively from and against all costs, losses, claims, demands, suits, actions, payments, and judgments, including legal and attorney fees, arising from personal or bodily injuries, property damage or otherwise, regardless of and however caused, brought, or recovered against any of the above that may arise for any reason from or during or be alleged to be caused by the undersigned’s participation in the Wilcox Senior Send-Off 2018.

The undersigned parent(s) or guardian(s) assume all risks in connection with the participation of the individual listed above in any and all of the PTA sponsored activities.

I/We attest and verify that the individual listed above is physically fit and able to participate in any PTA sponsored activities. Further I acknowledge that is it my responsibility to understand any inherent risks associated with PTA sponsored activities and communicate those risks to all individuals named above.

I/We do hereby certify that to the best of my knowledge and belief all individuals named above are 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(ren). 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 judgment 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.

I/We, as parent(s) or guardian(s) of the minor(s), do hereby, for my child/children, myself, my heirs, executors and administrators, release and forever discharge and 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 any individuals listed above in any PTA sponsored activities.

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 it of my own free will.

I/We further understand that any student possessing liquor or drugs, involved in a disruption or in any way presenting a danger to themselves or others, will be subject to removal from the premises and other appropriate action when necessary.

It is further understood that Senior Send-Off 2018 is not a Santa Clara Unified School District Function.

Medical Condition/Allergies *
I/We hereby advise that the above named minor has the following allergies, medicine reactions or unusual physical conditions, which should be made known to a treating physician: (If none, please write the word “none”. If yes, put first name of child and the allergy/condition.)
Your answer
Full Name *
(if minor, parent or guardian must compete this information)
Your answer
Today's Date *
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Acceptance of Terms *
Required
A copy of your responses will be emailed to the address you provided.
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