WAIVER / RELEASE FORM
Name of Youth Participant__________________________
Age: __________________ Gender: ______ Male _____ Female
Emergency Contact Name: ____________________________________
Emergency Contact number: ______________________
Please read carefully and sign:
By signing below you agree, warrant and covenant the following: As the parent or guardian, I certify that (PRINT YOUTH PARTICIPANT’S NAME) _________________________________has my permission to participate in the Run 2 Daylight Academy. I/We hereby delegate Run 2 Daylight Academy, their employees, clinicians, trainers, nurses, or agents the authority to seek, obtain, and approve any medical care and treatment including, but not limited to, X-Ray examination, and anesthetic, medical, dental or surgical diagnosis, or treatment and medical care which is deemed advisable by, and is, to be rendered under the general supervision of any physician or surgeon, for the above named minor which, in their judgment, is necessary for the health and well-being of said minor during his/her participation in the Run 2 Daylight Academy
I/We assign payment to those medical vendors for all services that these same medical vendors may render.
It is understood that this authorization is given in advance of any specific diagnosis, or treatment or medical
Care being required as is to serve as specific consent to any and all such diagnosis, treatment or hospital care which may be deemed advisable. I/We understand that I/We are responsible for any cost incurred that are not covered by insurance and we agree to hold Run 2 Daylight Academy, their employees or agents harmless for any liability arising out of any good faith actions taken in and obtaining medical treatment for the above-named minor. In consideration of the participant in the Run 2 Daylight Academy, the parent/guardian herby releases and holds harmless Run 2 Daylight Academy and their employees from any and all liability occurring during the above person’s participation. In particular the person’s parent/guardian acknowledges that he/she and such person will not hold Run 2 Daylight Academy liable for any expenses, property damages, and personal injuries and/or death sustained by such child while participating in the Run 2 Daylight Academy. Furthermore, the parent/guardian acknowledges that he/she has been, prior to the commencement of the Run 2 Daylight Academy, aware of and understands the risk involved in such activity, and is prepared to assume, on behalf of such child and himself/herself all of such risk as his/her and the child’s sole responsibility. It is understood that said child will be subject to the rules and regulations of Run 2 Daylight Academy. I understand that any person, who repeatedly disobeys Run 2 Daylight Academy policies or procedures, will be immediately expelled from the Run 2 Daylight Academy.
The terms and conditions of this Agreement shall be legally binding upon the undersigned parent/guardian and such child and his/her respective estate, representatives and assigns. As parent/legal guardian, I/We also give permission for photographs or video to be taken during Run 2 Daylight Academy activities. These photographs or video will remain the property of the Run 2 Daylight Academy and may be used in publications and marketing campaigns. I/We understand that the media will also be notified of the camp and therefore give permission for my child to participate in interviews and/or be filmed or photographed by camp approved news media outlets.
Please list any and all allergies or physical handicaps that the camp staff should be aware of (if none, please write NONE):
PARENT/LEGAL GUARDIAN Print Clearly) _____________________________________ PARENTS SIGNATURE__________________________________________________________________