(Student Last name, First name Middle Initial).

Transcription

1 (Student Last name, First name Middle Initial). Consent for Field Trip (P1a) DHS Band Combined Form P1a, P1b, P1c I hereby consent for the above named student to participate in athletic team, band, orchestra, chorus, and/or any other sponsored field trips. I understand that transportation may or may not be provided by the DeKalb County School System. In the event transportation is not provided by DCSS, transportation will be the student s responsibility. **Signature of Parent(s) or Guardian(s) Photo Opt-Out Statement (P1b) I withhold my permission for Dunwoody Band to display photographs, video images, or audio clips of my child, named above, in DHSBB publications. (Do not sign if it is OK for DHSBB to publish your child s photo, etc.) Signatures of parents(s) or guardian(s) Medication Policy and Consent Form (P1c) According to DCSS policy, ALL medication must be in the original container with the prescription/dosage clearly marked. These medications will be turned over to the Band and given out according to the prescription directions. No student is allowed to carry any medication. Chaperones will have Tylenol and Aleve, which can be given to students who have provided written permission below. STATEMENT OF PARENTAL CONSENT FOR TYLENOL OR ALEVE I hereby grant permission for my child named above to be given Tylenol or Aleve in the recommended dosage by a Dunwoody High School Band chaperone or teacher during Band Camp or Band event when needed, in the opinion of school authorities or chaperones. In such cases, I agree to waive, absolve, and hold harmless the DeKalb County School System, The Dunwoody High School Band, the Dunwoody High School Band Boosters, simply, or collectively from and against any injury or damage sustained by my child for which permission is given. Please indicate by circling as appropriate: Tylenol Aleve or Both Parent Signature: Date

2 (Student Last name, First name Middle Initial). DHS Band Combined Form P2a, P2b Consent for Medical Treatment (P2a) TO WHOM IT MAY CONCERN: I, the undersigned, being the parent or legal guardian of the above named student (birth date ) hereby grant authorization to the Band Director or any chaperone of the Dunwoody High School Band Boosters (DHSBB), standing in as local parents, to obtain any emergency medical and/or surgical treatment procedures from a physician or hospital emergency room physician on behalf of the above named minor. I also authorize the release of this student after receiving emergency treatment to the Band Director or any chaperone of the DHSBB. Waiver and Release I release and waive, and further agree to indemnify, hold harmless or reimburse the DeKalb County School System, the individual members, agents, employees and representatives thereof, as well as trip supervisors, from and against any claim which I, any other parent or guardian, any sibling, the student, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, from any losses, damages, or injuries arising out of, during, or in connection with the student s participation in the activity, any trip associated with the activity, or the rendering of emergency medical procedures or treatment. Date **Signatures of parent(s) or guardian(s) Financial / Insurance Information (P2b) For and in consideration for emergency services and goods rendered by or through the attending physician(s), the undersigned guarantees payment in full, immediately upon receipt of final billing. Date **Signatures of parent(s) or guardian(s) Insurance Carrier Policy No. TAPE COPY of FRONT AND BACK OF INSURANCE CARD BELOW or attach to this sheet

3 Sky Zone Roswell, GA Participant Agreement, Release and Assumption of Risk Please print and fill out completely or complete electronically at Parent/Guardian/Participant (if over 18): First Name Last Name Birth date Street Address Apt. # City State ZIP Cell Phone Check box if you would like to sign up for free text message promotions and discounts; Standard text message rates may apply from your service provider. In consideration of the services of Xtreme Air of Roswell, LLC (d/b/a Sky Zone Indoor Trampoline Park), RPSZ Construction, LLC, Sky Zone Franchise Group, LLC, Sky Zone LLC., their agents, owners, officers, affiliates, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (herein after collectively referred to as SZRC ), I hereby agree to release, indemnify, and discharge SZRC, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows: 1. I acknowledge that my participation in SZRC trampoline game or activities entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. The risks include, among other things: SZRC trampolines entail certain inherent risks that simply cannot be eliminated. Trampolines expose their participants to the risk of cuts and bruises. Other more serious risks exist as well. Participants often fall off equipment, sprain or break wrists, ankles and legs, and can suffer more serious injuries as well. Traveling to and from trampoline locations raises the possibility of any manner of transportation accidents. Participants often fall on each other resulting in broken bones and other serious injuries. Double bouncing, more than one person per trampoline, can create a rebound effect causing serious injury. Flipping and running and bouncing off the walls is dangerous and can cause serious injury and must be done at the participants own risk. There is also a risk of colliding with or being landed on by jumpers of a different size. In any event, if you or your child is injured, you or your child may require medical assistance, at your own expense. Furthermore, SZRC employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant s health or abilities. They may give incomplete warnings or instructions, and the equipment being used might malfunction. 2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks. 3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless SZRC from any and all claims, demands, or causes of action, which are in any way connected with my participation in SZRC activities or my use of SZRC s equipment or facilities including any such claims based upon damages caused or alleged to be caused in whole or in part by the negligent acts or omissions of SZRC. 4. Should SZRC or anyone acting on their behalf, be required to incur attorney s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs. 5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have. 6. In the event that I file a lawsuit against SZRC, I agree to do so solely in the state of Georgia, and I further agree that the substantive law of Georgia shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against SZRC on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms. I further grant SZRC, the right to photograph, videotape, and/or record me and/or my child/ward and to use my or my child s/wards name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising and promotional materials without reservation or limitation. I would like to receive free promotions and discounts to the address provided above. I may unsubscribe to s from Sky Zone at any time. Participant Signature (if 18 or older): Date: PARENT'S OR LEGAL GUARDIAN'S ADDITIONAL INDEMNIFICATION (Must be completed for participants under the age of 18) In consideration of (print up to four minors names/birthdates below of SAME parent or legal guardian): Participant 1: First Name Last Name Birthdate Participant 2: First Name Last Name Birthdate Participant 3: First Name Last Name Birthdate Participant 4: First Name Last Name Birthdate ( Minor ) being permitted by SZRC to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless SZRC from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor. I further certify that I am the parent or legal guardian of the minor on this agreement. Parent or Legal Guardian s Signature: Print Name: Date: Waiver accepted by (SZRC Employee) 06.12

4 This Page intestinally left blank

5 Tubing Participation Release of Liability and Assumption of Risk Agreement ***READ BEFORE SIGNING*** Organization Name Participant Name In consideration of being allowed to participate in any way in the program, related events and activities, I the undersigned, acknowledge, appreciate, and agree that: 1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death. 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation. 3. I willingly agree to comply with terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately. 4. By participating in or attending any activity in connection with this program, whether on or off the premises, I consent to the use of any photographs, pictures, film or videotape taken of me or provided by me for publicity, promotion, television, websites or any other use, and expressly waive any right of privacy, compensation, copyright or other ownership right connected to same, 5. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEM- NIFY, AND HOLD HARMLESS URBAN CURRENTS, INC., its officers, officials, agents and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (RELEAS- EES), from any and all claims, demands, losses, and liability arising out of or related to any INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHER, to the fullest extent permitted by law. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AND UNDERSTAND ITS TERMS, UNDER- STAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Participant s Signature Age Date FOR PARENTS/GUARDIANS OF PARTIClPANTS OF MINOR AGE (UNDER AGE 18 AT TIME OF REGlSTRATION) This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incidents to my minor child s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law. Parent/Guardian Signature Date Emergency Phone Number(s) 2479 Peachtree Rd NE Suite 1615 Atlanta, GA (404)