2021-2022 Participant Waiver
2021-2022 Parent's Approval; Student, Family, and Participant Waiver and Photo Release

This form is REQUIRED for every student to participate in any virtual or in person PTA sponsored event during the 2021-2022 school year. This includes, but is not limited to the following: School Assemblies & Programs, Spring Fling, Holiday Social, Walk to School Day, Croc-o-mile, Pancake Breakfast, Trunk or Treat, Jog-a-thon, Fundraisers, Carnival & Silent Auction.
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Email *
Student Name and Teacher #1 *
Please list the first and last name of your current Katherine Elementary School student and their teacher.
Student Name and Teacher #2
Please list the first and last name of your current Katherine Elementary School student and their teacher.
Student Name and Teacher #3
Please list the first and last name of your current Katherine Elementary School student and their teacher.
Student Name and Teacher #4
Please list the first and last name of your current Katherine Elementary School student and their teacher. If you have more than four students attending the school, please submit a secondary form with any additional students listed, or list them in the additional family member section (be sure to indicate their full name and teacher).
Additional Family Members *
List first and last names of all additional family members who may participate in PTA sponsored events (virtual or in person) or come on campus for PTA sponsored events. Remember to include older and younger siblings, grandparents, caretakers, relatives, etc.
Photo Release Permission *
I hereby grant and assign the California State PTA, its units, councils, districts and legal representatives, the irrevocable and unrestricted right to use and publish for editorial, trade, advertising or any other purpose and in any manner and medium, including website, social media, and internet promotion, all photographic, video, and digital images of the individuals listed above. Names of minor(s) will not be included with any photo use.* By signing below, I hereby release the California State PTA, its units, councils, districts and its legal representatives from all claims and liability relating to said photographs, video and digital images. *Please see separate release for Reflections and Junior Olympics.
Required
Waiver
The undersigned parent or guardian assumes all risks in connection with the family’s participation in any and all of the PTA sponsored activities (virtual or in person). I, the undersigned participant, intending to be legally bound, do hereby for my self and heirs, executors, administrators and assigns, forever waive release and discharge the California State PTA, all PTA officers, employees and agents from all liability, claims or demands for any damage, loss or injury to the student, the student’s property, or parent’s property or to myself in connection with participation in these activities, unless caused by the negligence of the PTA.I do hereby certify that to the best of my (our) knowledge and belief said parties are in good health. In case of illness or accident, permission is granted for emergency treatment to be administered. It is further understood and agreed that the undersigned will assume full responsibility for any such action, including payment of costs. I attest and verify that I am physically fit and able to participate in this event and acknowledge that I am aware of the inherent risks in participating in any athletic event.
Physical Conditions Alert *
I (we) hereby advise that the above named minor has had the following allergies, medicine reactions or unusual physical condition which should be made known to a treating physician or which could limit participation (include name if you have listed more than one child above). IF NONE, PLEASE WRITE NONE:
Parent/Guardian First & Last Name *
Parent/Guardian Telephone Number *
This information will only be used in the event of an emergency.
Parent/Guardian Address
Signature & Final Approval *
Required
Email Opt-In
A copy of your responses will be emailed to the address you provided.
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