By signing this form I give my informed consent to the First Aid personnel assigned by the Church in San Jose who are certified in a minimum of CPR and First Aid by a nationally recognized provider to provide basic First Aid and comfort measures through standardized treatment procedures, which includes the use of over-the-counter medications. I understand that it is my responsibility to make arrangements for a young person with greater healthcare needs than the First Aid personnel can provide within their individual certifications, licenses and scopes of practice. I authorize the Church in San Jose to arrange for or provide any necessary related transportation to the nearest medical facility for urgent or emergency medical treatment if indicated, and I do assume all responsibility for payment for such treatment. I hereby give permission to the physician selected by the Church in San Jose to secure and administer any and all medical treatment deemed necessary for my child, including hospitalization. This completed form may be photocopied for trips away from Sonoma State University ("SSU") properties.
I authorize the use of the following generic, over-the-counter medications as directed by the labels provided by the manufacturer for my child: analgesics, decongestants, antihistamines, cough suppressant and/or expectorants, throat lozenges or spray, anti- nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin and wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms and gels. I understand that these are stocked by the First Aid personnel and may be dispensed free of charge as needed for the comfort of my child.
I have requested the Church in San Jose to allow my child to participate in any and all activities that may include but are not limited to those outlined in the SST registration packet and/or web site. As a condition of receiving this benefit, I do hereby agree to the following: I understand that my child’s participation in these activities can expose him/her to dangers both from known and unanticipated risks. Acknowledging that such risks exist, I on behalf of myself, my child and any other party who may have the right to assert any rights for or on behalf of my child, do hereby forever release and discharge, indemnify and hold harmless the Church in San Jose, their affiliates, officers, directors, agents, employees, insurers, successors in interest, attorneys, or any other person or persons associated with any or all of them who might be liable (the “Released Parties”) from and against any and all claims, causes of action, actions, suits, demands, losses, damages, expenses, costs or liability (collectively, “Losses”) arising from or in connection with my child’s participation in the Church in San Jose events and its activities, including Losses arising from the negligence of any of the Released Parties, whether such Losses arise in connection with bodily injury (including death), property damage or otherwise (collectively, the “Released Claims”). The Released Claims include Losses arising out of any condition of the premises at which the SST activities are held or the conduct of any person in connection with the preparation for, supervision of, or conduct of any activity, whether planned or unplanned. I further understand and acknowledge that I make this release in full accord and satisfaction of and in compromise of any and all Released Claims.
I represent and acknowledge that I have read and understand this form and the release granted above and warrant that all statements made herein are true to the best of my knowledge. I have read and understand this entire form and by signing below agree to the terms herein.
