Liability Release Permission Form printable pdf download

LIABILITY RELEASE & PERMISSION FORM

medical treatment, and assume the responsibility of all medical bills, if any.

We (I) authorize an adult, in whose care the minor has been entrusted, to

RELEASE OF ALL CLAIMS

consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or

treatment, and hospital care, to be rendered to the minor under the general or

NAME________________________ CHAPTER________________

special supervision and on the advice of any physician or dentist licensed under the

BIRTHDAY____/______/______

SESSION________________

provisions of the Medical Practice Act on the medical staff of a licensed hospital,

whether such diagnosis or treatment is rendered at the office of said physician or at

Please run off one copy for each member who will be attending camp. Bring this

said hospital.

form, SIGNED BY PARENTS, with the registration fee to camp or mail in with

Further, should it be necessary for the participant to return home due to

registration.

medical reasons, disciplinary action or otherwise, we (I) hereby assume all

In consideration for being accepted by The Western Institute of Leadership

transportation costs.

for Life, Inc. for participation in the Wyoming FFA Leadership Camp (camp), we (I),

being 18 years of age or older, do for ourselves (myself) (and for and on behalf of my

Multimedia Recording and Usage Policy

child-participant if said child is not 18 years of age or older) do hereby release, forever

discharge and agree to hold harmless the Western Institute of leadership for Life, Inc.,

Western Institute of Leadership for Life, Inc. (DBA Wyoming FFA Leadership Camp)

the directors, counselors, and staff (the Organization) from any and all liability, claims

staff and its designees may capture photos, video and other recordings of participants

or demands for personal injury, sickness or death, as well as property damage and

before, during and after events at the Wyoming FFA Leadership Camp. Please be

expenses, of any nature whatsoever which may be incurred by the undersigned and

aware that all recorded media may be used by the Wyoming FFA Leadership Camp or

the child-participant that occur while said child is participating in the above described

with Western Institute of Leadership for Life, Inc.'s consent in future print materials,

trip and activity.

online materials including the official camp website ( ) and its

Furthermore, we (I) [and on behalf of our (my) child-participant if under the

official social media accounts, signage, slideshows, podcasts, videos and other uses in

age of 18 years] hereby assume all risk of personal injury, sickness, death, damage,

physical and digital forms. Attendance of Wyoming FFA Leadership Camp implies your

and expense as a result of participation in recreation and work activities involved

consent to be photographed, videotaped and otherwise recorded for these purposes.

therein. We (I) understand that attending camp is an FFA supported event and any

No individual or group may sell or distribute any Multimedia from Wyoming FFA

rules, guidelines, and/or laws according to state or school policy apply. We (I)

Leadership Camp without its consent.

understand the any personal property can be searched by a camp director, camp

staff, facility manager, state employee, and/or law enforcement member if deemed

necessary.

I have read and agree to the terms contained herein.

Further authorization and permission is hereby given to said Organization to

If under 18, a parent or legal guardian must sign unless parents are separated or

furnish any necessary transportation, food, and lodging for this participant. The

divorced, in which case the custodial parent must sign and date.

undersigned does also hereby give permission for our (my) child to ride in any vehicle

designated by the adult in whose care the minor has been entrusted while attending

and participating in activities sponsored by the Organization. We agree to the

_______________________________________________________ Date _______

Multimedia Recording and Usage Policy.

Parent or Legal Guardian Signature

The undersigned further hereby agrees to hold harmless and indemnify said

Organization, its directors, employees, counselors, and agents, for any liability

I have read the foregoing and understand the rules of conduct for participants and will

sustained by said Organization as the result of the negligent, willful, or intentional acts

abide by them as well as the directions of the leadership.

of said participant, including expenses incurred attendant thereto.

_______________________________________________________ Date _______

(If the participant has not attained the age of 18 years):

Participant’s Signature

We (I) are the parent(s) or legal guardian(s) of this participant, and hereby

grant our (my) permission for him (her) to participate fully in said camp, and hereby

Revised 04/01/2013

give our (my) permission to take said participant to a doctor or hospital and hereby

authorize medical treatment, including but not in limitation to emergency surgery or

Liability Release Permission Form

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