Loading...

Health and Permission Form

& Liability Waiver

If the event Participant is under 18, the section below is to be completed by the Parent or Guardian. Please answer the following questions as fully as possible. A doctor visit or physical is not required.

All of the below information is to the best of my knowledge, correct. I understand that participation in the James River Association (JRA) activities is entirely voluntary. I understand that the JRA event may involve “hands on” activities such as planting trees, using equipment, boating or wading in shallow water; and I understand the risks and dangers involved in the above-named activities. I know and understand that unanticipated dangers might arise. I hereby release JRA from any responsibility for injury which might occur as a result of participation in JRA activities. I give permission to authorize personnel to carry out such emergency diagnostic and therapeutic procedures as may be necessary for me/my child, and also permit such treatment procedures to be carried out at and by the local hospital(s) for me/ my child in the event of an emergency. I understand that any medical expenses will be billed directly to me or my insurance company. I hereby grant the James River Association the unconditional right to use me/my child’s name, voice, and photographic likeness of me/my child in connection with any of their audio video production, articles, website materials or press releases, but not as an endorsement.

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
Parent or Guardian's Email Address
Email
Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact
Emergency Contact Name *
Emergency Contact Phone Number *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Gender Identity*
He/Him
She/Her
They/Them
Prefer not to Disclose
Any known contact with Infectious Diseases within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, COVID 19 etc.)? If yes, please give details.
Any known Allergies/Health Conditions/Disabilities (e.g. attention-deficit disorder, heart condition, diabetes, etc. Please provide details about how staff can help your child thrive in our program. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Any Medicines/Treatments that need to be administered during the JRA program. (Please provide specific details here, and to school personnel, or in person to a JRA staff person when dropping off your student. Medications need to be in their original container, properly labeled with medication, dosage, and instructions).
Please note any other health related concerns.
I give permission for JRA staff to administer the following as needed for minor discomfort while on a JRA trip. (Check all that apply)*
Tylenol
Advil
Benadryl
Cough Drops
Antacid
Any of the above
None of the above
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!