SHOOT FOR COOP Child Waiver Form

SHOOT FOR COOP

AUTHORIZATION OF TEMPORARY GUARDIANSHIP
THE PARTIES TO THIS AGREEMENT ARE:

(All blanks must be completed, if not applicable enter N/A)
THE PARENT(s)/GUARDIAN(s):

(hereinafter referred to as "the Parent/Guardian")
FULL NAME
Date of Birth

MonthDayYear
Date
STREET ADDRESS
CITY
STATE
ZIP
RELATIONSHIP TO MINOR
DRIVERS LICENSE #
STATE
HOME PHONE
CELL PHONE
THE CHILD:

(hereinafter referred to as "the Child")
FIRST NAME
M.I.
LAST
Date of Birth

MonthDayYear
Date
THE TEMPORARY GUARDIAN(s):

(hereinafter referred to as "the Temporary Guardian")
FULL NAME
STREET ADDRESS
CITY
STATE
ZIP
CELL PHONE
I, the Parent/Guardian of the Child hereby grant temporary guardianship to the Temporary Guardian for the period from
Start Date

MonthDayYear
Date
and Expiring on Date

MonthDayYear
Date
1. I hereby acknowledge that the Child will reside with the Temporary Guardian and may travel locally with the Temporary Guardian and participate in off road and other outdoor motorized activities and/or shooting sports at the Shoot For Coop Fundraising Event on the DeSpain property, located at 14451 S FM 1174, Marble Falls, Texas 78654.

2. I authorize the Temporary Guardian to act on my behalf in making all decisions on a daily basis as to the Child's activities, well-being and welfare.

3. I authorize the Temporary Guardian to administer general first aid treatment for minor injuries or illnesses experienced by the Child except where any such first aid treatment is specifically excluded hereunder:
INITIAL
4. I authorize the Temporary Guardian, in the event that I cannot be contacted or if any urgency dictates, to act in loco parentis for the Child in respect of any circumstances, including any accident or illness, which may necessitate medical treatment, including surgery, and on my behalf to authorize any such treatment or surgery which they, in their sole discretion, (which discretion shall not be unreasonably exercised), may deem necessary. Medical treatment for the Child may also include dental surgery, x-ray, blood transfusion, anesthetic and medication provided any such medical treatment performed by a duly licensed practitioner. I hereby accept full liability for all costs incurred through such medical treatment for the Child.
5. Persons responsible should please note the following: Please state aspects eg. allergies, tendency towards abnormal bleeding, epilepsy, etc
Present prescribed or other medication that is being administered
6. The following information is essential in case of medical treatment or hospitalization:
6.1: Name and Address of Employer
6.2: Medical Aid/Insurer
6.3: Policy Number
7. I indemnify the Temporary Guardian against any and all claims whatsoever and howsoever arising, save where such claims arise from negligence, gross negligence or willful intent during the specified period of Temporary Guardianship.

8. I declare that I am the legal custodian of the Child and that I have legal authority to appoint a Temporary Guardian for the Child.

9. Unless inconsistent with the context, words signifying the singular shall include the plural and vice versa.

10. I agree to hold harmless George and Modena DeSpain, Shoot for Coop, volunteers, heirs members and/or directors from any claim to injury to your child.
Date

MonthDayYear
Date
Printed Name
SIGNATURE

Clear
Should be Empty:

SHOOT FOR COOP

THE PARENT(s)/GUARDIAN(s):

THE CHILD:

THE TEMPORARY GUARDIAN(s):