Youth Parent/Guardian Assumption of Risk Template

Your consent is required to allow such participation on an ongoing basis, however, your consent may be withdrawn at any time on a written notice delivered to [sport organization]

It is your responsibility to ensure that you are aware of your child’s volunteer activities with [sport organization]. [sport organization] will not contact you about such activities, but will provide information on request to you or any other authorized person.

Information about the Youth Volunteer and the Parent/Guardian/Authorized person

Full Name of Youth Volunteer: ____________________________________________________________

Date of Birth: ________ /______ / _________

Month Day Year

Youth Volunteer Email Address: ____________________________________

Emergency Contacts:

1. Name of parent/legal guardian/ authorized person: ________________________________

Relationship to Youth Volunteer: ___________________________________________________

Phone number: ________ - _________________

Street Address: ____________________________ Postal Code: ________________

1. Name of parent/legal guardian/ authorized person: ________________________________

Relationship to Youth Volunteer: ___________________________________________________

Phone number: ________ - _________________

Street Address: ____________________________ Postal Code: ________________

Safety and Risk Factors:

• [sport organization] strives to maintain a safe environment for volunteer activities and youth volunteers are to be provided with an orientation and training appropriate to the volunteer activity.
• Adults supervise the activities after the youth volunteer has arrived at the location for the volunteer activity. Supervision is not provided with respect to travel to or from any location and such travel does not form part of the volunteer activity or [sport organization] program unless otherwise advised. Similarly, there is no assured supervision for youth volunteers waiting to be picked up after the project. [sport organization] will request adult supervisors stay with the youth as long as they can. The youth volunteer will be allowed to take public transportation after the activity if they choose.
• Further information about safety and risk factors associated with specific volunteer opportunities is available by calling the [sport organization] at (____) -______-________. It is the responsibility of the parent/legal guardian/ other authorized person to inform themself about such risk factors and to determine whether the youth volunteer will be permitted to participate in a particular activity or program.

Consent and Release

In consideration of the youth volunteer being permitted to participate in the volunteer activity or program, the parent/legal guardian/other authorized person to provide consent in respect of the youth volunteer hereby:

• consent to participation by the youth volunteer in any program or activity of [sport organization] in which they choose to volunteer and agrees on behalf of the youth volunteer to assume all risks associated with such activities or programs;
• Releases [sport organization], and its directors, officers, employees, agents, contractors and other volunteers from any damage to property, personal injury or death, action, claim, cost, expense or liability whatsoever that they or the youth volunteer have, have had, or may have arising out of or occurring in connection with the youth volunteer’s participation in any program or activity of [sport organization]; and
• Agrees to indemnify and save harmless [sport organization], and its directors, officers, employees, agents, contractors and other volunteers from any damage to property, personal injury or death, action, claim, cost, expense or liability whatsoever that any other person has, has had or may have against them arising out of or occurring in connection with the youth volunteer’s participation in any program or activity of [sport organization].

Medical Information (This information is confidential. Collection, use and disclosure of this information will be for the purpose of ensuring the safety of the youth volunteer and [sport organization] staff.)

Allergies or other pertinent medical conditions that may be barriers to the youth volunteer’s participation in certain activities:

____________________________________________________________________________________________

____________________________________________________________________________________________

Family Physician: ______________________________ Phone #: ______________________________

Image Release

The parent/legal guardian/ other person authorized to provide consent in respect of the youth volunteer hereby consents to the use in any of [sport organization’s] publications of the youth volunteer’s image if contained in any photographs or other media created during programs or activities.

The terms of the above Safety and Risk Factors, Consent and Release, Medical Care Authorization, and the Image Release are hereby agreed to this _____ day of _______________, 20___. I confirm that I have read and understood the above terms and that I have the authority to sign this document in respect of the youth volunteer.

____________________________________ _____________________________

Name of Parent/Legal Guardian Name of youth volunteer (Print)

or other authorized person (Print)

___________________________________________

Signature of Parent/Legal Guardian or

other authorized person

_________________________________________

Witness (Print)

________________________________________

Signature of Witness