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Health and Permission Form

& Liability Waiver

With the recent challenges posed by COVID-19, the James River Association is asking participants to help us run programs as safely as possible. Please know that the risk of exposure to the COVID-19 virus cannot be completely eliminated. JRA asks each participant to fully evaluate your ability and willingness to participate in guidelines and understand the risks. 

I understand and agree that I will not participate in this activity if I have experienced any of the following symptoms in the 14 days prior to this activity: new or worsening cough; shortness of breath or difficulty breathing; fever greater than 100.4ºF; chills; unexplained muscle pain, sore throat, new loss of taste or smell. I also agree that no one in my household has exhibited the above symptoms or that I have knowingly been in contact with anyone with confirmed COVID-19 in 14 days prior to this activity.

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 Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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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
Sudafed
Antacid
Other listed above
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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
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.


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