Safety Guidelines for Secondary Interschool Athletics in Alberta

Continued from previous page
ACKNOWLEDGMENT OF RISKS/REQUEST TO PARTICIPATE/INFORMED CONSENT
AGREEMENT
I/We have read and understand the notices of accident insurance, transportation insurance and elements
of risk.
I/We hereby acknowledge and accept the risk inherent in the requested activity and assume
responsibility for my son/daughter for personal health, medical, dental, accident insurance coverage, and
ambulance transportation costs.
I/We request my son/daughter/ward to participate on the ___________________________________
team during the 20___-20___ school year.
I/We understand, appreciate and accept that there are inherent physical risks in the athletic activities my
son/daughter/ward will participate in. As a condition of my son/daughter/ward’s participation, I/we agree
that (name of School Board) will not be responsible for lost or stolen property, any injury, loss or
damage sustained by my son/daughter/ward unless such injury, loss or damage was caused by the sole
negligence of the (name of School Board) or its employees, servants, or agents arising from participation
in the above listed activities.
Signature of student athlete: __________________________________________________________
Date: ____________________________________________________________________________
Signature of parent/guardian: _________________________________________________________
Date: ____________________________________________________________________________
FREEDOM OF INFORMATION NOTICE
The information provided on this form is collected pursuant to the Board’s education responsibilities as
set out in the School Act and its regulations. This information is protected under the Freedom of
Information and Protection of Privacy Act and will be utilized only for the purposes related to the
Board’s policy on Risk Management for Interschool Athletics. Any questions with respect to this
information should be directed to your school principal.
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Safety Guidelines for Secondary Interschool Athletics in Alberta - February 2012