During the course of the 2018-19 school year, Pine Valley's PTA will host a variety of events and activities for our student and family community. We ask that all families, regardless of whether you know your availability to attend such events, please complete the following waiver at the onset of the school year. Pine Valley PTA strives to provide safe and inclusive programming for all our students and their families. Thank you!
Email address *
Parent/Guardian Name *
Your answer
Student FIRST NAME: *
Your answer
Student LAST NAME: *
Your answer
Additional Family Members:
Your answer
Will participate in PTA-sponsored events during the 2018-19 school year, which may include, but are not limited to the following:
Welcome Back Coffee, Odyssey of the Mind, Multicultural Events, Health and Wellness Week, Dances, 8th Grade Promotion Party, 8th Grade Breakfast, Reflections, Sister School Activities, Community Events, and/or Family Movie Nights.
The undersigned parent or guardian assumes all risks in connection with the family’s participation in any and all of the PTA sponsored activities.
I do hereby certify that to the best of my (our) knowledge and belief said parties are in good health and of sound mind. In case of illness or accident, permission is granted for emergency treatment to be administered. 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.
Parent / Guardian / Participant Signature: (Type first and last name for signature) *
Your answer
I/we hereby advise that the above named minor(s) 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
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. Parent / Guardian / Participant Signature: (Type first and last name for signature) *
Your answer
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. Parent / Guardian / Participant Signature: (Type first and last name for signature) *
Your answer
Mobile Phone Number: *
Including area code (XXX-XXX-XXXX)
Your answer
Address / City / Zip Code: *
Your answer
Thank you for completing this waiver.
A copy of your responses will be emailed to the address you provided.
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