ACTIVITY PARTICIPATION FORM

Park Ave. Field Day in Central Park

If you are interested in having your child participate in this event, please complete all sections of this form, sign and
return to Dori. Please contact Dori with any questions.
____________________ ______________________(Name of student) is interested in participating in the activity.

Please return this Activity Participation Form, as well as the Transportation Form , Medical Information and
Authorization to Treat a Minor and General Release of Liability Form with payment (cash or check made out to Fusion
Academy) by TUESDAY, DECEMBER 8.

NATURE OF ACTIVITY: Field Day in Central Park

DATE: Friday, May 5th, 2017
We will meet at Mineral Springs Park on West 67th at 1pm and play until 5pm. Students
TIME OF DEPARTURE: are responsible for getting to and from the field by themselves.

ANTICIPATED TIME OF Please plan on being at the field by 4:45 to pick up your child.
RETURN:
ACTIVITY SPONSOR: Morgan Geisert and Josh Chow
ACTIVITY INFORMATION: We will be meeting in the park for an afternoon of friendly Fusion Field Day fun!
COST: None
METHOD OF On their own
TRANSPORTATION:

Please place your initials after each statement below:

I understand the nature of the school activity in which my son/daughter will be participating and that
he/she is expected to abide by all school regulations during the course of the activity. _____
I acknowledge that I have signed the attached General Release of Liability Form. _____
I acknowledge that I have signed the attached Medical Information and Authorization to Treat a Minor
Form. _____
I acknowledge that I have signed the attached Transportation Release Form. _____
I hereby give my permission for him/her to participate in the above-described activity. _____

__________________________________________________________________________________________
Signature of Parent/Guardian Date

Parent Permission to Release Students to Authorized Person for Transportation

I, as parent or guardian, give permission for (print name of student) ______________________________ to be

transported to and/or from Fusion Academy located at _______________, during the period from ________________ to
_________________. I release Fusion Academy, its officers, employees, agents, and affiliated companies from any
liability arising out of personal injuries and/or property damage resulting from or in any way connected to my childs
transport to and from school.

(All parents/guardians must sign)

_______________________________________ _________________________
Signature of Parent/Guardian Home Telephone Number

_______________________________________ _________________________
Address Work Telephone Number
_______________________________________

_______________________________________

Date ___________________________________

_______________________________________ _________________________
Signature of Parent/Guardian Home Telephone Number

_______________________________________ _________________________
Address Work Telephone Number
_______________________________________

_______________________________________

Date __________________________________
 Medical Information and Authorization to Treat a Minor

Student Name: Parent Name/Ph #:

Student Cell Phone Number: Date:
*** THIS FORM WILL BE KEPT BY THE CHAPERONE DURING THE ACTIVITY***

List pertinent medication information (include severe allergies):

____________________________________________________________________________________

____________________________________________________________________________________

Emergency Contact Information:

Contact Name: Relationship to Student:
Primary Contact: Alternate Contact:

Authorization to Treat a Minor:

I (We), the undersigned parent, parents or legal guardian of ________________________________________,

a minor, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis
and treatment and emergency hospital care which is deemed advisable by an is to be rendered under the
general or special supervision of any member of the medical staff and emergency room staff licensed under
the provisions of the Medicine Practice Act and on the staff of any acute general hospital holding a current
license to operate a hospital from the state department of public health. It is understood that effort shall be
made to contact the undersigned prior to rending treatment to the patient but that any of the above
treatment will not be withheld if the undersigned cannot be reached.

________________________________________
Parent/Guardian Signature

_____________________
Date
 WAIVER AND GENERAL RELEASE OF LIABILITY

Required for all Sports, PE, and Extracurricular Participation

1. Permission and Voluntary Assumption of Risk: My child/ward has permission to participate in the Fusion Academy
and Learning Center sports and/or extracurricular program. Participation may include attendance at off-site activities
and sporting events. I understand and agree that my child/ward may be transported to activities in a school-owned
vehicle, or contracted/designated vehicle. I recognize that participation in (including trying-out, practicing, traveling to,
and playing) intramural, interscholastic, and recreational sport activities is a potentially hazardous activity posing
various safety risks, including risks of bodily injury, property damage, emotional injury, and other dangers associated
with participation in such activities. Dangers include but are not limited to: strains, sprains, cuts, bruises, broken bones,
concussions, heart attacks, paralysis, brain damage, and even death. Each participant, including spectators, in sports
activities should realize the risks and dangers inherent in such activities and in the training, preparation and travel to
and from such activities. I voluntarily assume all risks, both foreseeable and unforeseeable, arising from my
childs/wards participation with Fusion Academy and Learning Center team sports, whether caused by my or my
childs own actions or the actions of others.
2. Waiver and General Release of Liability: I waive, release, and forever discharge Fusion Academy and Learning
Center, its affiliated companies, board of directors, coaches, volunteers, managers, officials, and administrators from
any and all liability from injuries or damages arising out of or resulting from my childs/wards participation in or travel
to and from any activities associated with the Fusion Academy and Learning Center sports and/or extra-curricular
program. This is intended as a general waiver and release of all claims, including but not limited to the negligence or
omissions of individuals described above.
3. Emergency Medical Treatment: I authorize the Fusion employees in attendance at any Fusion Academy and Learning
Center activity to select and secure medical attention as may be necessary for my child/ward as a result of injuries or
other events requiring emergency care or first aide while I am not in attendance at such event. Fusion Academy and
Learning Center does not have its own insurance for sports and/or extra-curricular activities. This agreement waives the
schools financial responsibility for accidents related to such student activities.
4. Termination of Participation: Fusion Academy and Learning Center may terminate my childs participation
in any part of or all of a sports and/or extra-curricular activity whenever, in the sole judgment of the school,
continuation of the student's participation would be detrimental to the program or to the interests of the student.
5. Binding Effect: This agreement shall bind my heirs, representatives, executors, administrators and assigns.

___________________________________________ Date: _____________________________

Students Name

___________________________________________ Daytime Phone _____________________

Signature Parent or Legal Guardian

___________________________________________ Additional Phone ____________________

Print Name of Parent or Legal Guardian