Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Waiver: In consideration of being permitted to participate in any way in the Canyon Pole Vault Camp.
I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge
and covenant not to sue The Wm S. Hart School District, its officers, employees and agents
from liability from any and all claims including the negligence of The Wm S. Hart School
District, its officers, employees and agents, resulting in personal injury, accidents or illness
(including death), and property loss arising from, but not limited to participation in the Canyon HS
Pole Vault Camp.
X_____________________________________
Signature of Parent/Guardian of Minor Date
______________________________________________________________________________
Name of Minor (Print) Date of Birth Sport
Assumption of Risks: Participation in a Pole Vault Camp carries with it certain inherent risks that
cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one
activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains
to 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and
concussions to 3) catastrophic injuries including paralysis and death.
I have read the previous paragraphs and I know, understand, and appreciate these and
other risks that are inherent in the Canyon HS Pole Vault Camp. I hereby assert that my
participation is voluntary and that I knowingly assume all such risks.
Indemnification: I also agree to INDEMNIFY AND HOLD The Wm S. Hart District HARMLESS
from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities,
including attorneyŐs fees brought as a result of my involvement in the Canyon HS Pole Vault Camp
and to reimburse them for any such expenses incurred.
Severability: The undersigned further expressly agree that the forgoing waiver and assumption of risks
agreement is intended to be as broad and inclusive as is permitted by the law of the State of California
and that if any portion thereof is found in valid, it is agrees that the balance shall, notwithstanding,
continue in full legal force and effect.
Acknowledgement of Understanding: I have read this waiver of liability, assumption of risk and
indemnity agreement, fully understand its terms, and understand that I am giving up substantial
rights, including my right to sue. I acknowledge that I am signing the agreement freely and
voluntarily, and intend by my signature to be a complete and unconditional release of all liability
to the greatest extent allowed by law.
X_____________________________________
Signature of Parent/Guardian of Minor Date
*WAIVER IS NOT COMPLETE UNLESS ALL THREE (3) SIGNATURES ARE PRESENT. ONLY
ONE CAMPER PER WAIVER, NO SIBLINGS. CAMPERŐS CANNOT PARTICIPATE WITHOUT
SIGNED WAIVER.
RELEASE AUTHORIZATION FOR EMERGENCY TREATMENT
I understand that I am required to maintain and carry accident medical insurance coveragefor the child
listed on this application and I verify that the coverage information attached herewith is accurate and
true. In the case of an emergency, and I cannot be reached. I authorize the staff of the Canyon HS Track
to obtain whatever medical treatment he/she deems necessary for the welfare of
my child listed on this application. I further understand that I will be financially responsible for all
charges and fess incurred in the rendering of said emergency treatment, regardless of whether or not
my medical insurance would cover such charges and fees.
I am the parent/guardian of the minor _______________________________ and I am signing this
Release on behalf of said minor.
X_____________________________________
Signature of Parent/Guardian of Minor Date