CULPEPER COUNTY SHERIFF’S OFFICE
Parental Consent Form For Child Participant
Waiver/Release of Claims
I wish my child, the
above-named participant, to participate in the SHERIFF SCOTT H. JENKINS 1ST ANNUAL POLICE WEEK 5K hereinafter
“Activity” sponsored by the Culpeper County Sheriff’s Office on the following
date(s) MAY 17, 2014.
I have been given specific information orally
and/or in writing describing the nature of the Activity and the nature of the risks
and dangers involved.
I certify that I have listened to and/or read
the information about the Activity, and I understand the nature of the Activity,
its risks, and dangers. I understand and acknowledge
that some of the injuries and/or illnesses which may result from participating
in athletic activities including this specific Activity may include, but not be
limited to, exertion, sprains/strains, fractured bones, head or back injuries,
paralysis or even death.
NOTWITHSTANDING, and with full
and complete understanding of all dangers and risks the Activity involves, I
voluntarily consent to my child’s participation in the Activity and assume full
responsibility and all risks of any kind, including personal and bodily
injuries, death, and property damage that may be sustained as a result of my
child’s participation in the Activity.
I agree to hold harmless Culpeper County, its Board of
Supervisors, and/or the Culpeper County Sheriff’s Office, including their
officers, directors, employees, agents and volunteers (the “County”) from any claims,
liabilities, or causes of action of every nature and kind (including the cost
of investigation) arising out of any act or omission by me or my child which
involves, or in anywise relates to, my child’s participation in this Activity.
I agree that the County may
discontinue the Activity or require my child to leave the Activity or the
premises on which the Activity is conducted at any time for any reason.
I authorize the
County to seek emergency medical treatment for my child and to arrange for his
or her transportation to a medical facility in the event of a medical emergency,
a determination that I agree shall be within the discretion of the County if I
am not present at the Activity to make such determination myself. I also authorize the County to disclose the consent of this form
to any medical agency, medical staff engaged in providing medical services that
may be required in the event of a medical emergency involving my child.
I CERTIFY that I am: 1) the parent or legal guardian of the
above-referenced child participant, 2) over eighteen (18) years of age; 3)
mentally competent to consent to my child’s participation in the consenting to
release Culpeper County, its Board of Supervisors and/or the Culpeper County
Sheriff’s Office of any and all claims
that may arise out of my child’s participation in the Activity. I further consent that this Consent and
Waiver/Release and Assumption of Risk shall be binding on the child, all other
natural or adoptive parent(s) of my child, my heirs, executors, next of kin and
assigns, or any other person who may claim by or through me. I
acknowledge that the County has offered me no compensation, medical payments
coverage, or other benefits in connection with the Activity.
CAUTION: READ THE FOREGOING
RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK BEFORE SIGNING. THIS
DOCUMENT IS VALID UNLESS AND UNTIL REVOKED IN WRITING AND REVOCATION DELIVERED
TO CULPEPER COUNTY.