2897 Kilgore Road
Rancho Cordova, CA 95670
(916) 875-9627
www.rcpdpal.org
FIELD TRIP / ACTIVITY CONSENT FORM

Event:
STEM Classes  |  Life on Planet Earth!  |  Grades 6th - 8th
Date/Time:
June 21 - June 24  |  1:00pm - 4:00pm
Location:
Rancho Cordova City Hall; 2729 Prospect Park Dr.

Please complete the entire form. Children's Information:

Sex:
Child lives with:

Father/Mother/Guardian (Please list the BEST way to reach you)

Emergency Contact (Other Than Parents or Guardians)

Photo Release

I grant to Rancho Cordova Police Activities League, its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize the Rancho Cordova PAL, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that the Rancho Cordova PAL may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

and

AGREEMENT OF INDEMNITY RELEASE OF LIABILITY
AND ACKNOWLEDGEMENT OF RISK OF ACTIVITIES

I acknowledge and realize and am aware that my child will be participating in a variety of activities. I understand that there are elements of risks in any activity associated with participation. These risks include, but are not limited to, falling, tripping, being hit by another child, getting injured in a vehicle which is providing transportation, etc. I also acknowledge and understand that although Rancho Cordova PAL staff and volunteers may be present; those persons are not always able to prevent the possible injuries from risks that have been described above.

Therefore, I agree as follows:
1. Release
As a condition of and in consideration for being permitted by Rancho Cordova PAL to participate in the activities provided, I for myself and/or minor children for which I am a parent/legal guardian or otherwise responsible, any heirs, personal representatives, or assigns do hereby release, discharge, and covenant not to sue the Rancho Cordova PAL, its employees, principles, directors, officers, agents, volunteers, or anyone affiliated with the Rancho Cordova PAL and each/every landowner, municipal and/or governmental agency upon whose property an activity is conducted from all liability and waive any claim for damages arising from any cause whatsoever, except that which is the result of gross negligence.

2. Express Assumption of Risk and Responsibility
In recognition of the inherent risk of the activity which I and any minor children for which I am responsible, will engage in, I confirm that my child is physically and mentally capable of participating in this activity and using the equipment. My child is participating willingly and voluntarily. I assume full responsibility for personal injury, accidents and/or illness, including, but not limited to, sprains, torn muscles, bites, wounds, scrapes, abrasions and/or contusions; head, neck and/or spinal injuries, bites or attacks by animals or insects, allergic reactions, shock, paralysis, coma or death, and any related expenses that are related to my child. I assume all responsibility for damage to or loss of my/our personal property as a result of any accident that may occur.

3. Hold Harmless/Assumption of Risk
I agree that I/we will indemnify and hold harmless the Rancho Cordova PAL, the City of Rancho Cordova and the County of Sacramento, and any affiliated organization, its representatives, its employees, principles, directors, officers, agents, volunteers, or anyone affiliated with the City of Rancho Cordova and the County of Sacramento and each and every landowner, municipal and/or governmental agency upon whose property and activity is conducted, from any loss, all liability and waive any claim for damages or costs arising for any cause whatsoever related to my child’s participation, except that which is the result of gross negligence.
I further expressly agree that this assumption of risk, release and indemnity agreement is intended to as broad and inclusive as is permitted by the laws of the State of California and if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I also agree to take any, all and full responsibility for any interactions that occur relating to an employee of the City/County who is in any fashion associated with or having contact with my child outside the specific hours of the program.

4. Medical / Insurance Information

Do you have INSURANCE?:

5. MEDICAL RELEASE: AUTHORIZATION CONSENTING TO TREATMENT OF MINOR

I/We, the undersigned, parent(s) or legal guardians of

a minor, do hereby authorize the staff of the Rancho Cordova Police Activities League, or an authorized representative, as agent(s) for the undersigned, to consent to any X-Ray examination, anesthetic, medical or surgical diagnosis, treatment and hospital care which is rendered under the general or specific supervision of any physician and surgeon licensed under the provisions of the California Medicine Practice Act on the medical staff of a licensed hospital, whether such examination, diagnosis, or treatment is rendered at the office of said physician or at such hospital.
It is understood that this authorization is given in advance of any specific examination, diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of our above named agent(s) to give specific consent to any and all such examinations, diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may seem advisable.

I HAVE READ THE FOREGOING (Items 1 - 5) ACKNOWLEDGEMENT OF RISK, ASSUMPTION OF RISK AND RESPONSIBILITY, RELEASE OF LIABILITY, HOLD HARMLESS AGREEMENT, AND MEDICAL INFORMATION AND RELEASE. I UNDERSTAND THAT BY SIGNING THIS DOCUMENT, I AM WAIVING VALUALBE LEGAL RIGHTS. I DO SO VOLUNTARILY. I DO SO WITH FULL UNDERSTANDING THAT THE RANCO CORDOVA PAL, THE CITY OF RANCHO CORDOVA AND THE COUNTY OF SACRAMENTO ARE NOT TO BE HELD RESPONSIBLE, WHATSOEVER, OR AT ALL FOR INJURIES THAT MAY OCCUR TO ME AND/OR ANY CHILD OF MINE EXCEPT THAT WHICH IS CONCLUSIVELY DETERMINED TO BE THE RESULT OF GROSS NEGLIGENCE.
BY SIGNING AND VALIDATING THIS AS A PARENT OR GUARDIAN, I HEREBY AGREE THAT I AM DULY AUTHORIZED TO DO SO ON BEHALF OF MYSELF AND ON BEHALF OF ANY OTHER PARENT OR GUARDIAN TO THE PARTICIPATING CHILD.

STEM Program Waiver

ACCIDENT WAIVER AND RELEASE OF LIABILITY -- I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH THIS EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.I certify that I am physically fit, have sufficiently prepared or trained for participation in this activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity. In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, (B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.I acknowledge that this activity may involve a test of a person's physical and mental limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, volunteers, monitors, and/or producers of the activity. These risks are not only inherent to participants, but are also present for volunteers. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity.I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors, organizers, and assigns. The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

Parental Consent -- As the parent or legal guardian, I hereby consent to my child's information to be used to create third party online accounts for educational purposes. Student privacy is primarily governed by two federal laws: the Federal Educational Rights and Privacy Act (FERPA) and the Children's Online Privacy Protection Act (COPPA). FERPA generally prohibits educational agencies and institutions from disclosing personally identifiable information from a student's education records to a third party without written consent from the parent (or the student if over age 18). COPPA protects children under the age of 13 who use commercial websites, online games and mobile apps. While educational agencies and institutions have an obligation to make sure the services their students use treat the data they collect responsibly, COPPA ultimately places the responsibility on the online service operator.