File: JJHA-E-2



    Print   Name of Student/Participant (on line   above)

    Print   Student’s Parent or Guardian Name (on   line above)

    Daytime   Phone Number

    Print   Student’s/Parent’s Address, City, Zip Code (on line above)

    Evening   Phone Number


    Start   date:

    End   date:



    1. Have you, the Parent/Guardian, determined that your Student/Participant may, and should be permitted to, drive him/herself to the Event/Activity identified above?



    1. If you’re answer to A. above is Yes, is your Student/Participant currently licensed and eligible to drive a motor vehicle in Massachusetts; and is his/her license presently in his/her possession (if so, please attach a copy of your Student/Participant's driver's license, both sides)?



    1. Have you discussed with your Student/Participant the responsibilities associated with safely driving him/herself to the Event/Activity, and are you confident that your Student/Participant can and will comply with the conditions set out below regarding his/her self-transport?



    If the answers to A, B, and C above are Yes, please complete the following:


    I, _____________________ (print name), am the parent or guardian of the Student/Participant identified above, who is a student at ___________________________ (print name of school). With my knowledge and permission, the Student/Participant has elected to participate in Event/Activity that I have described above ("Event/Activity").

    I acknowledge and understand that Sharon students occasionally travel to other schools or other sites (separately or collectively, "Site") outside of Sharon for school-related or associated events/activities. I further understand that the Sharon School Department routinely and ordinarily arranges for free transportation for students to travel to and from these events/activities, including the Event/Activity identified above. Nonetheless, in order to accommodate the Student/Participant identified above (who wishes to drive him/herself to and from the Event/Activity) and in consideration of the Student/Participant's being permitted to participate in the Event/Activity, we (Parent/Guardian and Student/Participant) each represent (Section 1) and agree to the following (Section 2):

    Section 1 - Representations

    1. The Student/Participant is licensed to operate motor vehicles in Massachusetts;
    1. His/her license is current and is not currently revoked, suspended, or subject to restrictions (other than vision qualifications);
    1. The Student/Participant has established to the satisfaction of Parent/Guardian that he/she is a capable and defensive driver, is compliant with traffic laws, and has not engaged in driving that is unsafe to him/herself or others; and,
    1. The Student/Participant, in connection with the Event/Activity identified above, shall limit his/her driving to the hours of 6:00 a.m. - 10:00 p.m., and shall confine his driving to the Commonwealth of Massachusetts.

    Section 2 - Release

    Because we have each voluntarily chosen and elected to have the Student/Participant transport him/herself in connection with the Event/Activity, we each understand that it is our responsibility, not the School Department’s, to assure that the Student/Participant safely travels to and from the Site where the Event/Activity is taking place. By signing below we each release, discharge and agree to defend, indemnify and hold harmless the Town of Sharon, the School Committee, School Department and all their past, present and future officers, agents, servants, employees and attorneys (collectively “Town of Sharon”) from any and all liability, whatsoever for any and all damages, loss or injuries (including death), sustained by the Student/Participant or his/her property, or both, including but not limited to any third-party claims, demands, causes of action, judgment, damages, expenses, and costs, including attorney’s fees and costs of suit, which arise out of, occur during, or are in any way connected to the Student/Participant’s travel to and from the Event/Activity (and related Site).

    We each represent and agree that the Student/Participant will not transport any other Sharon students in connection with the Event/Activity listed above (and related Site), unless such students are siblings of Student/Participant.

    We each agree that if any portion this document is held to be invalid, the balance hereof shall, notwithstanding, continue in full legal force and effect.

    In signing this document we each hereby acknowledge that we have each read this entire document, that I understand its terms, that by signing it we each are giving up substantial legal rights that each of us may otherwise have, and that we have each signed it knowingly and voluntarily.

    By my signature below, I also certify and represent that I have legal custody of the Student/Participant by reason of the fact that I am the parent of the Student/Participant, or his/her legal guardian by court order.

    Student   Participant


    Parent   or Legal Guardian


    Revised:December 11, 2013