(To be filled out by all participants)

It is the policy of the Shepherd School District to require a signed liability release before
allowing anyone to participate in a non-school activity on school property.

I/We fully understand that some activities involve inherent risks to me/my child regardless of
reasonable safety measures that may be taken by the District.  In consideration of the District’s
agreement to allow me/my child to participate in open gym, I agree to accept responsibility for
any loss of injury to me/my child that occurs during my/my child’s participation that is not the
result of fraud, willful injury of the willful or negligent violation of a law by a trustee, employee
or agent of the School District.

I/We agree that if the District’s rules and regulations are not complied with, the District may
deny me/my child the privilege of participation in non-school activities that take place on school
property;

I/We agree to retain and to have in place at all times an insurance policy that covers any loss,
damage, or injury to me/my child and by executing this agreement state I/We have such
insurance;

I/We agree to release, indemnify and hold harmless there from the District, for itself, officers,
Board Members, administrators, employees, agents, sureties, assigns, successors, insurers, and
indemnitors from any and all sums of money, accounts, suits, proceedings, claims, causes of
action, rights, damages, attorney’s fees, costs and demands of any nature whatsoever, whether
real or contingent, known or unknown, direct or indirect, liquidated or otherwise, arising our of
or relating in any way to my/my child’s participation in non-school activities that take place on
school property.

In the event it becomes necessary for the School District staff to obtain emergency care for
me/my child, neither he/she nor the School District assumes financial liability for expenses
incurred because of an accident, injury, illness and/or unforeseen circumstances.