MAY 17th, 2024 PARENTS NIGHT OUT

MAY 17th, 2024 Parent Night Out Registration Form

Parent/Guardian First Name:

Phone Number

Youth First Name:

Parent/Guardian Last Name:

Address

Youth Last Name:

Additional Siblings Names for Registration:

Any Special Health Needs:

Assumption of Risk and Use of Equipment Release

As a parent or guardian of a student planning to participate in summer activities, I hereby acknowledge that I have read, understood, and agree to do the following:

I acknowledge that the activity listed above entails many risks of injury, even when played in an instructional clinic environment. These risks of injury include, but are not limited to, death, serious neck and spinal injuries (which may result in complete or partial paralysis), brain damage, serious injury to virtually all internal organs, bones, joints, liga- ments, muscles, tendons and other aspects of the muscular skeletal system, and serious injury or impairment to other aspects of the body, general health, and well-being.

I further certify that my child has no medical or physical conditions which could interfere with his/her safety in this activity or else I am willing to assume and bear the costs of all risks that may be created, directly or indirectly, by and such condition.

Medical Release

In the event of an accident or illness, I understand that reasonable effort will be made to contact the parent/guardian immediately. However, if I am not available, I authorize the Everett School District to secure emergency medical care as needed.

Name of Preferred Doctor:

Doctor Phone Number:

Medical Insurance:

I understand that I am assuming financial responsibility for medical expenses that may arise from my child’s participa- tion and that the Everett School District requires but does not provide medical insurance for my child. I certify that my child has current medical coverage under the following plan:

Health Insurance Carrier:

Plan Number:

I am fully aware of the special dangers and risks inherent in participating in on or off campus summer activities in the sport listed previously, including physical injury and/or death. I hereby waive, release, absolve, indemnify, and agree to hold harmless Everett School District youth camps employees, suppliers, sponsors, and participants for any and all liability and for any and all injuries or illness incurred while at camp. Being fully aware of the risks, I hereby give per- mission for my son/daughter to participate in the activities initialed on page one of this document.

Emergency Contact Name and Relationship:

Emergency Contact Phone Number:

Children Age(s)

Your Signature

Select an item ($)

1 Child - $30

2 Children - $55

3 Children - $80

4+ Children - $100

Thanks for submitting!

Henry M. Jackson
High School FOOTBALL

MAY 17th, 2024 PARENTS NIGHT OUT

MAY 17th, 2024 Parent Night Out Registration Form

Henry M. Jackson HighSchool - Mill Creek, WA

Jackson HS Football Booster Club