Country Club Elementary School: Country Club PTA 2024-2025 Student/Family/Participant Waiver

Email address: *

Parent/Guardian name: *

STUDENT first Name: *

STUDENT Last Name: *

Additional Family Members:

The undersigned parent(s) or guardian(s) assume all risks in connection with the participation of all individuals
listed above in any and all of the PTA sponsored activities.
I attest and verify that all individualslisted above are 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 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 agree.

Use the space above to sign your name

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:

None

(If none, please write the word “none”. If yes, put first name of child and the allergy/condition.):

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.

Parent/Guardia signature (type first and last name): *

Address and phone: