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teen academy waiver form .pdf


Original filename: teen academy waiver form.pdf
Author: tmcleod

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WAIVER OF LIABILITY AND RELEASE AGREEMENT
City of Oregon Police Division Teen Police Academy
Summer 2019

I hereby acknowledge that I am the parent/guardian of a participant less than 21 years of age, and that said participant
has my permission to participate/attend the City of Oregon Police Division Teen Police Academy that will be held at the
Oregon Police Training Facility.
I hereby agree to release and discharge all claims against the City of Oregon, Ohio, their officers, agents, employee’s,
elected officials or representatives for any property damage or personal injuries of any kind that may occur during said
event. I do hereby release and forever discharge the City of Oregon, Ohio, their officers, agents, employees, elected
officials or representatives of and from all claims, demands, actions, suits, causes of actions, whatsoever arising out of or
related to any loss, damage, or injury including death that may be sustained by my son/daughter/dependent or to any
property belonging to my son/daughter/dependent, whether caused by the negligence of the City of Oregon, their
officers, agents, employee’s, elected officials or representatives, or otherwise participating in the above Teen Police
Academy program, or while in, on or upon the premises where the activity is being conducted or in transportation to
and from said premises.
I further agree to indemnify and hold blameless the City of Oregon, their officers, agents, employee’s, elected officials or
representatives from any loss, liability, damage or costs including court costs and attorney fees that may incur due to my
participation in the Teen Police Academy program, whether caused by negligence of the City of Oregon, their officers,
agents, employee’s, elected officials or representatives or otherwise.
In the event my representative or I cannot be reached in an emergency and reasonable attempts to contact me or my
representative have been unsuccessful, I hereby give my permission for the administration of any treatment deemed
necessary by a doctor or dentist, selected by the adult leader in charge of the event, and the transfer of the child to any
hospital reasonably accessible which also includes the hospitalization, securing proper anesthesia and/or to order
injection for my son/daughter/dependent.
I, the undersigned, have read and understand the above stated waiver and release agreement.

____________________________________
Participant’s PRINTED Name

_____________________________________
Signature of Parent/Guardian

____________________________________
Date

_____________________________________
Phone Number

____________________________________
Printed Name of emergency contact

_____________________________________
_____________________________________
Alternate Emergency Name & Phone #

Any Known Food Allergies?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
________________________________________________________________


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