Please complete one waiver per student who may participate in any Hewes PTA-sponsored events (such as Color Run, Special Assemblies, PTA Student Store, Fun Friday lunch activities etc.) for the 2023-24 school year. This waiver needs to be completed ONCE PER SCHOOL YEAR by a parent or guardian ONLY.

Once completed, your form will be automatically submitted to our records when you click on the “Submit” button. After clicking on “Submit”, a message on your screen will say: “Thank you! Your student’s information has been submitted and recorded.” Please note: No email confirmation will be sent. If you have questions, contact mrepitman@gmail.com.

This form only needs to be completed ONCE PER SCHOOL YEAR to cover all PTA-sponsored events.

Student Last Name

Student First Name

Grade

Birth Date

MM

DD

YYYY

Parent/ Guardian Approval for PTA-Sponsored Activities

The undersigned parent or guardian assumes all risks in connection with the participation of the above named individual in any and all of the PTA sponsored activities. I attest and verify that the individual listed above is physically fit and able to participate in any PTA sponsored activities. Further I acknowledge that is it my responsibility to understand any inherent risks associated with PTA sponsored activities and communicate those risks to the individual named above. I do hereby certify that to the best of my knowledge and belief all individuals named above are in good health. In the event that I, or other parent/guardian, cannot be reached in an emergency, I hereby give permission to secure proper treatment for my child(ren). I/we do hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon or dentist and performed by or under the supervision of the medical staff of the hospital or facility furnishing medical or dental services. It is further understood that the undersigned will assume full responsibility for any such action, including payment of costs. I, as parent or guardian of the minor, do hereby, for my child/children, myself, my heirs, executors and administrators, release and forever discharge and hold harmless the California State PTA, the local PTA and all officers, directors, employees, agents and volunteers of the organizations, acting officially or otherwise, from any and all claims, demands, actions or causes of action which in any way arise from the participation of any individuals listed above in any PTA sponsored activities.

I have read and agree to the aforementioned regarding PTA sponsored activities.

Medical Allergies

I hereby advise that the above named minor has the following allergies, medicine reactions or unusual physical conditions, which should be made known to a treating physician: If none, please write “NONE”.

Parent/Guardian Electronic Signature

By typing my first and last name below, I confirm that I have carefully read and fully understand this waiver and its contents. I am aware that this is a release of liability and I have signed it of my own free will.

Date

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent Phone Number

(###)

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