ࡱ> DICq bjbjll C0efefJJ4$88888z<       $;"DD88Y 888D" o0"""{hT7DDj"JX : FONTANA UNIFIED SCHOOL DISTRICT Fontana, California INTRAMURALS WAIVER AND MEDICAL AUTHORIZATION I,_______________________________________________, hereby give my permission for my child, _______________________________________________, to participate in the following school-sponsored but non-required activity: NAMEOF SCHOOL: Alder Middle School ACTIVITY: Intramural Sports LOCATION: Alder Middle School DATE: TIME: 12:30 1:45/ 2:00 Every Wednesday TEACHER: Mr. Cavazos I agree that my child will abide by all the rules and regulations governing conduct during the field trip/event. I agree that if my child is determined to be in violation of behavior standards during a trip/event, he/she may not be permitted to participate in future field trips/events. I agree to allow my child to participate in this non-required field trip/event. In consideration of offering the opportunity for participation in this non-required event, on behalf of my child I agree for any purpose, including, but not limited to observation, use of facilities or equipment or participation in any way, the undersigned hereby acknowledges, agrees that THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the FONTANA UNIFIED SCHOOL DISTRICT (hereinafter referred to as releasees') from all liability to the undersigned or their child for or any loss or damage, and any claim or demands therefor on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releasees or otherwise, while the undersigned is in, upon, or about the premises or any facilities or equipment therein. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in, upon or about the Ƶ premises or in any way observing or using any facilities or equipment of the school district or its vendors or agents whether caused by the negligence of the releasees or otherwise. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to the negligence of releasees or otherwise while in, about or upon the premises of the school district or its vendors or agents and/or while using the premises or any facilities or equipment hereon. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. All persons making the field trip or event shall be deemed to have waived all claims against the District or the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion. (Ed. Code 35330) Such waiver shall extend to and include the Districts officers, employees, and agents. In the event of any illness or injury, I hereby consent to whatever X-ray, examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary by the licensed physician for the safety and welfare of my child. I agree that the resulting expenses will be my responsibility as the parent(s), guardian(s), or participants. (If and when possible, contact with the parent/guardian will be attempted prior to a medical procedure or action being taken, unless a licensed physician determines that medical action must be taken without parental contact.) ______________________________________________________________________________________________ Signature of Parent/Guardian Street Address __________________________________________________________________________________________ City Home phone Date ______________________________________________ Fathers Work Phone_________________________ Signature of Student (if over 18 years of age) Date Mothers Work Phone________________________ _______________________________________________________________________________________________ Parents Health Insurance Policy Number IN THE EVENT OF EMERGENCY AND UNABLE TO CONTACT ABOVE, PLEASE CONTACT: _____________________________________________________________________________________________ Name Address Phone SPECIAL NOTE TO PARENTS: (1) All medicines must be registered on this form; (2) all medicines, excepting those which must be kept on the students person for emergency use, must be kept and distributed by the staff; (3)________check here if there are any special needs that the staff should be aware of and any medicines required on the trip; (4) if any medication is to be taken by the student, list them here:___________________________________________ If your son or daughter needs an accommodation, please attach a description of any accommodation needed for your child. NOTICE, THE SCHOOL DISTRICT DOES NOT CARRY STUDENT ACCIDENT INSURANCE.  4?@ab     0 : > H I \ ] f g r x y 貪蚌vk]UhCKCJaJhYi1hx}5>*CJaJh.,5>*CJaJhYi1hYi15>*CJaJhYi1CJaJhYi1h _5>*CJaJh _CJaJh9CJaJh#CJaJhqIhCJaJhCJaJhx}CJaJhS1hx}5CJaJh5CJaJhCK5CJaJhS1hx}CJaJhqIhhx}5CJaJ 4ab: ] y  z,$a$gdfO$a$gdx}$a$gdqIh J K R Ĺ򹮹򗌃wlddd\ThCJaJh?JCJaJh1]CJaJhS1h)CJaJhc|hc|5CJaJhx}5CJaJh5>*CJaJh 5>*CJaJhCKhx}>*CJaJh#5>*CJaJhTX5>*CJaJhc|CJaJhTXCJaJhCKCJaJhJ5>*CJaJhS1hx}CJaJhYi1hCK5>*CJaJR n t   2 ? 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