CHA Inc. Release of Liability and Harm
I hereby grant full permission for my child, __________________________,to participate in CHA Inc. Athletics programs marked below for the 2010/2011 school year. I certify that my child is physically fit and adequately trained to participate in such events, excepted as noted, ________________________.
By my signature below, I, ______________________, the parent/guardian of
_______________________________________, grant my permission for him/her to participate fully in the athletic programs designated below, including transportation to and from such events, and to allow the use of any pictures taken for use in CHA Inc. yearbook or programs.
I understand that my signature carries with it the following:
1. I hearby release CHA Inc., its volunteer staff, agents, and subsidiaries in whole and individually from any and all responsibility for any harm, injury, sickness, which may result to above named participant as a direct or indirect result of participation from aforementioned activity. I waive any right to hold CHA Inc. liable for any such harm, injury, or sickness.
2. In the event of illness, injury, or other medical emergency, I authorize first aid and/or professional medical care to be administered to the above named participant. If required by the medical care provided, I hereby grant specific power of attorney to the adult leader in charge of said activity to allow him/her to consent to medical treatment. In so doing, I release adult leader from any harm, injury, illness resulting from said medical treatment.
3. I acknowledge that I am financially liable for any medical care provided, and shall not hold CHA, Inc. and/or its agents, or the medical provider liable for any medical expenses or costs incurred as a result of medical treatment which may be rendered.v
4. Authorization: I have read and completed all of the above Consent Form and agree to all the statements, limitations, authorizations, waivers, and provisions listed therein.
Signature: ___________________________ Date: ______________________
SPORT(S):
Soccer ______ Volleyball _______ Basketball _________ Baseball __________
INSURANCE: Company _______________ Policy Holder: __________________
Group/Account Number _________________ Date: _________________