2018 iMPACT SHIPROCK – REGISTRATION FORM

Parent/Guardian Consent Form

PLEASE PRINT CLEARLY - Must be enrolled for school year 2018-2019. Ages 7 – 18 years old.

PARTICIPANT’S NAME: AGE: DOB:

T-shirt Size:
YOUTH or ADULT:
SCHOOL NAME (2018-2019): GRADE:
____________

Contact #1 AND Contact #2 - PARENT/GUARDIAN/CARETAKER NAME(S): 1. Phone #:

2. Phone #

MAILING ADDRESS: CITY: STATE: ZIP:

Physical Address (please be specific, provide detailed information):

Allergies and/or Medication(s)? Physical Limitation(s): Other information:

Planned ACTIVITIES (subject to change based on availability of equipment, space, and/or personnel):
Basketball, Volleyball, Soccer, Roller Skating, Vacation Bible School, Nature Hike, Obstacle Course,
Running, Swimming, Arts & Crafts, Board Games, Educational Activities, Golf, Bowling, Football,
Softball, Baseball, Music & Drama, Painting
Participation in certain activities including, but not limited to, basketball, volleyball, football, basketball, track &
field, etc. may result in injuries such as spinal injuries, broken bones, head injuries, and death. iMPACT SHIPROCK and
the Central Consolidated School District does not provide any accidental death, disability, dismemberment or
medical expenses insurance on behalf of the participant’s participation in these activities. It is strongly recommended
that you arrange private coverage.
I/WE understand that certain activities require a minimum LEVEL OF FITNESS AND HEALTH (physical, mental and
emotional) and that each person has a different capacity for participating in these activities. I/WE hereby agree and
promise that our child, ward or self is physically fit to participate and understands that the CHOICE to participate
brings with it the ASSUMPTION OF THOSE RISKS AND RESULTS which is part of these activities.
I/WE agree that the iMPACT SHIPROCK and the Central Consolidated School District or its Staff shall not be
liable for any injury to our child, ward or self or loss or damage to the property arising from, or in any way resulting
from, participation in these activities, UNLESS such injury, loss or damage of our child, ward or self is caused by the
SOLE NEGLIGENCE of the Staff acting within the scope to their duties.
I/WE fully understand that any participant, observer, volunteer, employee, parent, may DIRECTLY or INDIRECTLY,
have their photo taken at the sites of IMPACT SHIPROCK events for the sole purpose of documentation and promotional
purposes.
I/WE fully understand that iMPACT SHIPROCK and the CENTRAL CONSOLIDATED SCHOOL DISTRICT ARE NOT
RESPONSIBLE FOR ANY ACCIDENTS, INJURIES, DAMAGES, OR STOLEN PROPERTY.
I/WE declare having read and understood the above INFORMED CONSENT AGREEMENT in its entirety and hereby
consent to participate acknowledging all of the foregoing.
Please initial:

_______ YES, I give my child permission to be transported by the CCSD school bus for activities.
_______ For the safety and protection of my child; I understand that my child will be NOT be allowed to walk
home. I will ensure that my child is picked up at 2pm. I am aware that Social Services will be contacted if my
child is not picked up at 2pm.

Signature of Parent or Guardian _______________________________________________ Date:

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