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Central Unified Performing Arts Return to Activity 2020-21- Rio Vista Middle School

Please complete the form below. Required fields marked with an asterisk *

As the parent/guardian of the above-named child and on behalf of myself and my child, agents, heirs, and successors, I voluntarily agree to:

Assume all risks of injury, illness, or death to my child arising out of or resulting from my child’s participation in and/or attendance at the above-stated program or activity, such risks to include but are not limited to, injury, illness, or death due to being exposed to or infected by contagious diseases, including COVID-19
Waive and release all claims, causes of actions, actions, liabilities, and costs against the Central Unified School District (District) and its governing board and members thereof, officers, employees, agents, and volunteers (collectively District Personnel) and hold harmless the District and District Personnel from any claims, causes of actions, actions, liabilities, and costs that may arise out of or result from my child’s participation in or attendance at such program or activity;
Assume all obligations for any medical, financial, and other costs and/or liabilities that be sustained or incurred by my child, myself, or my agents, heirs, and/or successors. The District assumes no responsibility and shall not be liable for any injury, illness, death, liabilities, damages, or costs that my child, myself, my agents, heirs, and/or successors may sustain or incur arising out of or resulting from the aforementioned program or activity.

Contact Information

Student's First Name*

Answer required for "Student's First Name"

Student's Last Name*

Answer required for "Student's Last Name"

Date of Birth*

Answer required for "Date of Birth"

Parent/Guardian First Name*

Answer required for "Parent/Guardian First Name"

Parent/Guardian Last Name*

Number Required

Email Address*

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Address

Street Address*

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City*

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Zip/Postal*

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Home Phone*

Number Required

Alternate Phone*

Number Required

Emergency Contact*

Answer required for "Emergency Contact"

Relationship*

Answer required for "Relationship"

Home Phone*

Number Required

Alternate Phone*

Number Required

Registration should be done prior to return to activity starting. Participants will be placed in a pod with a specific time. If the participants register on the same day as the activity starts, they will not start that day. They will be assigned a group/pod and time for the next day. Every participant must agree and complete this form prior to participating in any activity. *

Answer required for "Registration should be done prior to return to activity starting. Participants will be placed in a pod with a specific time. If the participants register on the same day as the activity starts, they will not start that day. They will be assigned a group/pod and time for the next day. Every participant must agree and complete this form prior to participating in any activity. "

I agree with CUSD Return to Activity Policy

I DO NOT agree with CUSD Return to Activity Policy

Please check the following if you are signing this document digitally. *

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My digital signature serves as an original handwritten signature

Parent/Guardian: Please type your full name in the box below. *

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Confirmation Email

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