Drop-Off Activity Waiver

Student Full Name Student Name Grade Grade*

Student Full Name Student Name Grade Grade

The above student (s) has (have) my permission to participate in the following activity, field trip, testing administration, club, or program to be held at Type a label on Date Time

Please select the activity*

Parent/Guardian Name:*

First NameLast Name

Please list anything that your student (s) may need in order to participate in this drop-off event safely or type NA: *

Who is your HST?*

Please list the first and last name of any individuals who have permission to drop off and/or pick up your student from this event (please note that event leads will only release students to following names listed below):*

FOR STUDENTS WHO ARE 16 YEARS OR OLDER:

I authorize my student, who is at least 16 years of age and possesses a valid California driver’s license, to sign themselves in and out of this drop-off event without my presence. I understand that by granting this permission, my student will be responsible for their own transportation to and from the event, and I release the organization and its representatives from any liability related to my student’s independent travel

If you marked the authorization above, please type the student's name below.

First NameLast Name

PARENTS/GUARDIANS, PLEASE NOTE: It is a privilege, not a right, to participate in extra-curricular activities; the privilege may be revoked at any time. The acceptance and inclusion of student is at the discretion of HEARTLAND and subject to program standards and criteria. Student shall comply with all applicable codes of conduct and maintain high ethical and moral standards.

ASSUMPTION OF RISK: By signature hereon, parent/guardian waives liability against and holds harmless the school and its board members, staff, volunteers, vendors, agents; the school district; and State of California; and further acknowledges that this voluntary activity and/or transportation to and from (as applicable) may expose the student to potential harm including injury or death. If student believes that an unsafe condition or circumstance exists with respect to activity(s), student will discontinue participation and immediately notify school staff. Student shall not further participate until the unsafe circumstance is remedied.

By signing below:

(1) I am giving up substantial actual or potential rights in order to allow the student to voluntarily participate in this activity(s);

(2) I have signed this agreement with full appreciation and understanding of the risks inherent in the activity(s);

(3) I have no question regarding the intent of this agreement;

(4) I, as parent or guardian, have the right to bind myself, the student and any other family member, representative, assign, heir, trustee or guardian to the
terms of this agreement; and

(6) I have explained this agreement to the student, who understands his/her obligations hereunder.

Parent/Guardian Email Address*

example@example.com

Authorized Signature of Parent/Guardian*

Date*

Date

If it becomes necessary for my child to have emergency medical care while participating in this activity, I hereby give school personnel permission to use their judgment in obtaining emergency medical care for the child, and I give permission to the physician selected by school personnel to render medical care deemed necessary and appropriate by the physician. I understand that the school carries student accidental injury insurance in an amount limited to $50,000 (applies excess of family health insurance if applicable.)

Student Name*

First NameLast Name

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Home Phone:*

Please enter a valid phone number.

Work/Mobile Phone:

Please enter a valid phone number.

Emergency Contact Phone:*

Please enter a valid phone number.

Parent/Guardian Name:*

First NameLast Name

Authorized Signature of Parent/Guardian:*

Date*

Date

PLEASE PROVIDE INSTRUCTIONS FOR SPECIAL MEDICAL TREATMENT AND/OROVER-THE-COUNTER MEDICATION FOR THE STUDENT WITH THIS FORM.

AGREEMENT FOR ACTIVITY PARTICIPATION AND AUTHORIZATION FOR MEDICAL CARE

AUTHORIZATION FOR EMERGENCY MEDICAL CARE