Georgia Cyber Academy
1745 Phoenix Blvd., Ste. 100
Atlanta, GA 30349
https://www.georgiacyber.org/
Tel: 404-334-4790
If you speak another language, language assistance services are available free of charge. Email Julie Ferrer jferrer@georgiacyber.org
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Por favor de enviarme un correo electrónico Julie Ferrer, jferrer@georgiacyber.org
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Julie Ferrer jferrer@georgiacyber.org
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. Julie Ferrer Jferrer@georgiacbyer.org
यान द: य द आप हद� बोलते ह तो आ प के ि◌लए म
ु
त म भाषा सहायता सेवाएं उपलध ह Julie Ferrer jferrer@georgiacyber.org
رادرﺑﺧ: رﮔا پآ ودرا ﮯﺗﻟوﺑ ںﯾﮨ، وﺗ پآ وﮐ نﺎﺑز ﯽﮐ ددﻣ ﯽﮐ تﺎﻣدﺧ تﻔﻣ ںﯾﻣ بﺎﯾﺗﺳد ںﯾﮨ ۔ لﺎﮐ Julie Ferrer Jferrer@georgiacyber.org
State Charter School District: 782 | School Code: 0120
LIABILITY RELEASE AGREEMENT
Minor's Legal Name (Print) ___________________________________________________________________________ (If there is more
than one child per family participating, please provide their legal name(s)):
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
(collectively referred to as "Minor") wishes to participate in ____________________________________ ("Activity") sponsored by
Georgia Cyber Academy (GCA).
GCA and the undersigned parent or legal guardian of Minor agree that the Activity may pose risks, including possible illness,
injury as well as similar and dissimilar risks ("Risks"). The undersigned is fully aware of the Risks and other hazards inherent in the
Activity and is participating in the Activity voluntarily and assumes the Risks and all other risks of loss, damage, or injury that
may be sustained while participating in the activity.
GCA makes no representations or claims as to the condition or safety of the land, structures, transportation or surroundings
that may be involved in the Activity, whether or not owned, leased, operated or maintained by GCA. It is understood that
GCA does NOT provide any insurance coverage for the Minor's person or property, and Minor's parent (s) or guardian (s)
acknowledge that they are responsible for the Minor's safety and the Minor's own health care needs, and for the protection
of the Minor's property.
In exchange for allowing the Minor to participate in these GCA Activities, the Minor, by and through the undersigned, the
undersigned, and their respective heirs, personal representatives and estates agree(s) to release from liability, indemnify and
hold harmless GCA and any agent, officer or employee of GCA acting within the scope of their duties for any injury to the
Minor's person or damage to the Minor's property or any other claim, demand, cause of action, liability, damages, costs and
expenses (including reasonable attorney’s fees). I authorize GCA to take any action, including seeking medical care,
necessary in its judgment if I am not present or reachable in the event of an emergency. The undersigned acknowledges
that as a part of this Release he or she shall be 100% liable to pay for all medical expenses resulting or to result from any injury
incurred during, or as a result of, participation in the Activity.
If any term of this agreement or the application to any person or circumstance shall, to any extent, be invalid or
unenforceable, the remainder shall not be affected thereby, and each and every remaining term of this agreement shall be
valid and enforced to the fullest extent permitted by law. In the event of any need to enforce this agreement, GCA shall be
entitled to its attorney fees and costs.
I, the undersigned, state that I am the parent or legal guardian of the Minor. l have fully read and understand the above
terms and conditions and that they apply to said Minor and to myself, and that no oral representations, statements or
inducements apart from the foregoing written agreement have been made to the undersigned. This document is binding on
myself, the said Minor, and any person suing on behalf of said Minor.
Please note, lack of consent to participate in school and/or district events does not exclude students from testing
requirements.
Parent/Guardian Name (Please print): __________________________________________________________________________________
Address:__________________________________________________________________
City:_____________________________________ State: ____________________________ Zip: __________________________
Signed: _____________________________________________________________________________Date: _____________________________
click to sign
signature
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