SRO Waiver Form(s)

Date: * +

All Youth Must Have a PCJC Health & Waiver Form *

PCJC Health & Waiver Form

Waiver Forms: (Select All Program Waivers that Apply) *

School District: *

School Name: *

School Official Name: *

School Official Email: *

PIERCE COUNTY JUVENILE COURT PROGRAM PARTICIPATION PARENT/LEGAL GUARDIAN CONSENT/RELEASE FORM

PIERCE COUNTY JUVENILE COURT PROGRAM PARTICIPATION BY YOUTH
PARENT/LEGAL GUARDIAN CONSENT/RELEASE FORM

This form must be completed and signed by the parent/guardian of the participant at the start of each probation period. This form will be kept on file in the event the youth is assigned or ordered to a program offered by Pierce County Juvenile Court.

Dear Parents:

Your child may be referred to one or more programs through Pierce County Juvenile Court in their partnership through the Bethel School District. State law requires that all participants under the age of eighteen (18) years old have on file a Consent/Release form signed by their parents or legal guardian.

Below is an outline describing the responsibilities of the program supervisor and the Participant:

1. All participants are to be informed by staff that there will be some strenuous physical activity involved in the activity. Although all individuals in average health will be able to comfortably participate, it shall be each individual's responsibility to notify their assigned supervisor at the start of each program day of any health condition or medication issues that might interfere with their ability to comfortably participate in the activity
2. Some activities will involve more risk than one engages in during normal daily routines, i.e., bending, lifting, lawn care, and painting. Each individual must be informed by staff of the risk involved and the skills necessary to safely complete the activity. The participant will engage in the activity based upon the state’s minor employment guidelines.
3. All the activities are potentially dangerous. Participants must be informed by staff of the risks inherent in any activity and the prescribed safe response in order for the participant to assume responsibility for the risk.
4. Programs referred to by Pierce County Juvenile Court provide limited accidental medical insurance for the youth in excess of any other collectable medical insurance.
5. Possession and/or use of alcoholic beverages, tobacco, or drugs is strictly prohibited on program property and/or while participating in a county activity. Prescription medication and any diet concerns must be reported to the assigned supervisor before the program day begins.

I, Parent/Legal Guardian Name the undersigned, give my consent for my child, Youth Name, to participate in Programs offered through Pierce County Juvenile Court. I hereby release Pierce County, its employees, and volunteers from any and all liability relating to the above-mentioned person's participation in the Pierce County program. This release includes my authorization to allow Pierce County Juvenile Court to transport my child to and from the site of the program and/or activities. I understand if my child is terminated early from any program due to behavior concerns, I am required to pick up my child from the program/activity site, or if unable to do so, I authorize my child to be given a bus ticket to take the bus home.

I, give my permission for my (youth name), Youth’s photographs, quotes or videotape images to be used for publicity in publications or other media formatted.

It is necessary that the Pierce County Juvenile Court have parental authorization for the child to be left unattended if the parent(s) are unable to be at the pick-up site at the end of the day. Please sign the authorization form below and submit to the probation officer or designated Pierce County Juvenile Court Staff.

I hereby authorize the Program supervisor to deliver my child to the drop-off site and leave him/her unattended at the site until I arrive to pick up my child. I also approve of emergency care for the above individual, under the direction of the program supervisors or consulting doctor, even if I cannot be contacted. (Cross out the last statement if you do not wish to grant medical consent.) If there are any changes to the above information, including insurance information, it is my responsibility to notify the probation department.

*This form remains in effect until revoked by Parent/Guardian in writing. To do so, submit a written notice, with current date, and deliver to your child’s Probation Officer or Diversion Case Worker.

PCJC HEALTH FORM

1. Do you have any physical complaints or chronic illness at this time? *

Yes

No

If so what: *

2. Have you had injuries in the past (i.e. back, knee, shoulder, elbow, etc.)? *

Yes

No

If so what: *

3. Are you under the care of a physician of any sort? *

Yes

No

If so what: *

4. Are you taking medicines of any type? *

Yes

No

If so what: *

5. Are you on a special diet? *

Yes

No

If so what: *

6. Do you have or have you ever had:

a. Diabetes? *

Yes

No

Are you taking insulin? *

Yes

No

What Kind: *

How Much? *

b. Asthma? *

Yes

No

c. Allergies? *

Yes

No

If yes, please list to what: *

d. Are you allergic to bee stings? *

Yes

No

Explain: *

e. Any other disorders? *

Yes

No

If yes, please list to what: *

Metals

LIABILITY WAIVER

Liability Disclaimer: I release, indemnify, and hold harmless Alchemy from all liability in connection with any injury in conjunction with the participation activity (ies) which include all activities connected to skateboarding. I acknowledge that there are potential risks associated with Skateboarding. I appreciate and assume all risks associated with participating in these events.

I certify that I am in good health, able to participate in activities, and competent to enter this release. (If under 18 years of age, a parent or guardian MUST sign this release). I have read the foregoing release, authorization and agreement, before entering my full name (or electronic signature) below and warrant that I fully understand the contents thereof.

Publications Release: I give Alchemy Skateboarding permission to photograph me and use my picture in any medium for any purpose. I hereby waive any right to approve the finished products.

YOUTH INFORMATION

Youth Full Name *

DOB * +

Age *

Gender *

Male

Female

Height *

Weight (lbs.) *

Street Address *

City *

State *

Zip Code *

Youth Phone (Home)

Youth Phone (Cell)

Email Address

Best Way and Time to Reach the Youth

Doctor's Name *

Doctor's Phone Number *

Medical Insurance

Group ID#

Youth Signature *

clear

PARENT/GUARDIAN INFORMATION

Parent/Guardian Full Name *

Parent/Guardian Initials *

Is Parent/Guardian Address the Same as Youth? *

Yes

No

Street Address *

City *

State *

Zip Code *

Relationship to Youth *

Phone Number (Home/Cell) *

Phone Type *

Home

Cell

Phone Number (Work)

Parent/Guardian Email *

Parent/Guardian Signature *

clear

Best Way and Time to Reach the Parent/ Guardian

EMERGENCY CONTACT INFORMATION

Full Name *

Phone Number *

2nd Cycle	Arts Connect	Changing Rein-Hands on Horses
Changing Rein-Agility	Circle of Growth	Evening Center
Elements	Exhale	HAC4E
Metals	Mountaineers	OSH-Life Coaching
Outdoor Life	Tacoma Boat Builders