LOOMIS GRAMMAR SCHOOL PTC SOAPBOX DERBY
PHONE NUMBER: ______________________ DATE OF BIRTH: ___________________________________
EMERGENCY CONTACT: NAME:____________________________________________________________
PARENTAL CONSENT, AGREEMENT & RELEASE FROM LIABILITY,
ASSUMPTION OF RISK & INDEMNITY AGREEMENT
1. Voluntary Participation. I, __________________________________________________, acknowledge that I have voluntarily
(Name of participant)
applied to participate in the Soapbox Derby Competition/Event being put on my the Loomis Grammar School Parent Teacher Club.
2. Parental Consent. I consent to the Minor's participation in the Soapbox Derby Competition/Event and HEREBY ACCEPT AND
ASSUME ALL SUCH RISKS, KNOWN AND UNKNOWN, AND ASSUME ALL RESPONSIBILITY FOR THE LOSSES COSTS
AND/OR DAMAGES FOLLOWING SUCH INJURY, DISABILITY OR DEATH, EVEN IF CAUSED, IN WHOLE OR IN PART,
BY THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW.
3. Assumption of Risk. I AM AWARE THAT A SPEED COMPETITION OF THIS TYPE IS A HAZARDOUS ACTIVITY. I AM
VOLUNTARILY PARTICIPATING IN THIS ACTIVITY WITH KNOWLEDGE OF THE DANGERS INVOLVED AND HEREBY
AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH AND VERIFY THIS STATEMENT BY PLACING MY
Initials of volunteer AND parent/guardian)
4. Release. As consideration for being permitted by the Loomis Grammar School Parent Teacher Club to participate in this activity
and use related facilities and equipment, I hereby agree that I, my assignees, heirs, distributees, guardians, and legal representatives
will not make a claim against, sue, or attach the property of the Event Organizers, the Loomis Grammar School Parent Teacher Club.
Loomis Grammar School, the Loomis Union School District, Del Oro High School and/or their agents and employees on account of
injury or damage resulting from the negligence or other acts, howsoever caused, by the Event Organizers, the Loomis Grammar
School Parent Teacher Club. Loomis Grammar School, the Loomis Union School District, Del Oro High School or their employees or
agents as a result of my participation in the Soapbox Derby Competition/Event. I hereby release Event Organizers, the Loomis
Grammar School Parent Teacher Club. Loomis Grammar School, the Loomis Union School District, Del Oro High School and its
agents and employees from all actions, claims, or demands that I, my assignees, heirs, distributees, guardians, and legal
representatives now have or may hereafter have for injury or damage resulting from my participation in the Soapbox Derby
5. Agreement to Indemnify. If, despite this release, I, the Minor, or anyone on the Minor's behalf, makes a claim against any of the
"Releasees" named above. I AGREE TO DEFEND, INDEMNIFY AND SAVE AND HOLD HARMLESS THE RELEASEES and
each of them from ANY LITIGATION EXPENSES, ATTONEY FEES, LOSS, LIABILITY, DAMAGE, OR COST THE MAY
INCUR DUE TO THE CLAIM MADE AGAINST ANY OF THE "RELEASEES" NAMED ABOVE, WHETHER THE CLAIM IS
BASED ON THE NEGIGENCE OF THE RELEASEES OR OTHERWISE.
6. Knowing and Voluntary Execution. I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS
CONTENTS. I AM AWARE THAT THIS IS A PARENTAL CONSENT, RELEASE OF LIABILITY, ASSUMPTION OF RISK
AND INDEMNITY AGREEMENT AND A CONTRACT BETWEEN ME AND THE EVENT ORGANIZERS, THE LOOMIS
GRAMMAR SCHOOL PARENT TEACHER CLUB. LOOMIS GRAMMAR SCHOOL, THE LOOMIS UNION SCHOOL
DISTRICT, DEL ORO HIGH SCHOOL, AND SIGN IT OF MY OWN FREE WILL.
Executed on _________________________ at the Town of Loomis, California.
Signature of Volunteer: ______I HAVE READ THIS RELEASE_________
Date: ________________________ Signature of Parent/Guardian______I HAVE READ THIS RELEASE_________
Date: ________________________ Signature of Coordinator: _________________________________________________