I HAVE READ AND UNDERSTAND THE BELOW INFORMATION
As parent/guardian of the above student, I certify that they are in excellent health and have no  
physical, mental or emotional problems which are likely to prevent participation.
I understand that the Lovettsville PTO and/or CLINIC PROVIDER do not provide any 
medical payments coverage (insurance) and I am allowing my child to participate in this 
event at their own risk.  By checking the box above, I agree to pay for any medical expenses
incurred by my child as a result of participating in this Lovettsville PTO sponsored activity and
of participating in this Lovettsville PTO-sponsored activity and will not hold the PTO Instructor
or the staff liable for any reason related to my child’s participation in the program. I also give
permission for my child to receive medical treatment, first aid, emergency medical care, and all 
other medical or surgical deemed reasonably necessary to my child's health and well-being in case
of accident, injury, or serious illness during participation in the activity and understand that I, or
my insurance, will be responsible on a primary basis for any medical bills incurred.
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