Ashburton PTA Student Emergency Information and Participation Waiver
*Please fill out a separate waiver for each Ashburton Elementary Student* and/or for each non-Ashburton kid who is attending our PTA event.

The undersigned parent or guardian of the individual listed below assumes all risks in connection with the family’s participation in any and all of the PTA sponsored activities.

I, the undersigned participant, intending to be legally bound, do hereby for my self and heirs, executors, administrators and assigns, forever waive release and discharge the Ashburton Elementary School PTA, all PTA officers, employees and agents from all liability, claims or demands for any damage, loss or injury to the student, the student’s property, or parent’s property or to myself in connection with participation in these activities, unless caused by the negligence of the PTA.

I do hereby certify that to the best of my (our) knowledge and belief said parties are in good health.  In case of illness or accident, permission is granted for emergency treatment to be administered.  It is further understood and agreed that the undersigned will assume full responsibility for any such action, including payment of costs.  

I recognize that participation in these events creates a possible exposure to and illness from communicable diseases, including but not limited to, influenza or COVID-19.

I knowingly assume all risks associated with the contraction of any such disease, even in the case it arises from the negligence of others.

My choice to participate in any events held by Ashburton Elementary School PTA means that I assume all responsibility associated with the contraction of a communicable disease.

I understand that Ashburton Elementary School PTA is not liable for the contraction of any communicable disease or the follow up care, and I / my family members (if applicable) are participating at our own risk and discretion.

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Email *
First and last name of legal guardian submitting this form and waiver. *
Phone number *
Street Address *
City *
State *
Zip Code *
Student's First Name *
Student's Last Name *
Student's Grade *
Please list any allergies, medicine reactions or unusual physical condition which should be made known to a treating physician or which could limit participation. If not applicable, enter N/A. *
Name of first emergency contact and relationship to student. *
Phone number of first emergency contact *
Name of second emergency contact and relationship to student.
Phone number of second emergency contact.
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