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 hereinafterActivity” 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.