I hereby request that JSerra Catholic High School ("JSerra") permit my student(s) identified above to participate in the foregoing activity. I am aware that there are certain risks associated with such participation. I hereby knowingly and voluntarily assume any and all such risks. Moreover, for valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I, individually and on behalf of my minor child, hereby knowingly and voluntarily release, acquit, and discharge JSerra, and each of its officers, directors, employees, agents, volunteers, and representatives, of and from any and all liability, claims, demands, and/or causes of action, relating to or arising from such participation.
I hereby authorize JSerra personnel, as agent for the undersigned, to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and render under the general or special supervision of any physician and/or surgeon licensed under the provisions of the Medical Provisions Act on the medical staff of any accredited hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent to give specific consent to any and all such diagnosis, treatment or hospital care, which the aforementioned physician, in exercise of his best judgment, may deem advisable.