THE FOLLOWING ARE NAMES AND CONTACT NUMBERS OF THE ONLY PERSONS AUTHORIZED TO PICK UP MY STUDENT(S) FROM THE AFTER SCHOOL PROGRAM.
PLEASE LIST ANY SPECIAL MEDICAL PROBLEMS, ALLERGIES, ETC., THAT WE SHOULD KNOW ABOUT.
DISCLAIMER: Although Bay View Academy strives to assist identified allergic program participants in avoiding exposure to allergens, Bay View Academy cannot guarantee the elimination of allergens from the program environment. If your student requires emergency medication such as asthma inhaler or epinephrine to accompany him or her, please complete the Authorization for emergency Medication form.
AUTHORIZATION TO TREAT: I authorize the adult agents and employees of Bay View Academy in charge of the program to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care to be rendered to above names minor student under the general special supervision and upon the advice of a physician and surgeon licensed under the provision of the Medical Practice Act, pursuant to Section 25.8 of the California Civil Code and agree to be responsible for all cost thereby incurred.
In consideration for being allowed to participate in Bay View Academy recreational programs, I, the undersigned, agree to indemnify, hold harmless, and release Bay View Academy, it’s employees, agents, independent contractors, volunteers, officials, and officers from negligence, accepting gross negligence, and any and all liability for any injury which may be suffered by me, my minor student(s), or any member of my household account (hereinafter collectively the “Household Members”) arising out of, or in any way connected to participation in any Bay View Academy sponsored recreational program and agree to refrain from bringing the claim, lawsuit or other proceeding against Bay View Academy stemming from any such personal injury. I agree to take responsibility to ensure that all Household Members enroll in activities at the appropriate level for their physical abilities and medical conditions and fully understand that I and Household Members assume all risk for any injuries received. I expressly acknowledge that risks, known and unknown, are inherent in recreational programs. I authorize Bay View Academy employees and agents to seek emergency medical care, as they deem necessary, for any Household Member participating in any Bay View Academy sponsored recreational program and agree to be responsible for all costs incurred. I acknowledge that Bay View Academy may take publicity photographs and/or recordings of any Bay View Academy sponsored activity or event and hereby authorize the use of any Household Member’s image for this purpose. If any term, clause, or provision of this Release of Liability is held to be illegal, invalid or unenforceable, the remainder of the Release of Liability shall not be affected thereby and shall be enforceable to the fullest extent permitted by law. The undersigned agrees that signatures on registration forms that are transmitted to Bay View Academy by facsimile or electronic mail shall have the same force and effect as original signatures.
I have read and understood the above agreement and fully assume all risks for any injuries received.
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