Medical Form

In order for students to participate in the USC, parents/guardians must complete a Medical Waiver form.


Covid-19 Waiver/Disclaimer

By signing this waiver, I acknowledge the potential risk of exposure to the novel coronavirus (“COVID-19”); and I hereby release, discharge, defend, indemnify and hold harmless the Urban Scholastic Center (“USC”), its employees, agents, and representatives, of and from any claims, including all liabilities, actions, damages, costs or expenses of any kind arising out of or relating to COVID-19. I understand and agree that this release includes any claims based on the actions or omissions of USC, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any USC activity. I understand and agree that my signature below represents a signature on behalf of myself and each of my children.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to all parties, USC will conduct a simple screening prior to your child(ren) entering USC’s campus. Your participation is important to help us take precautionary measures to protect you, your child(ren) and everyone on campus.

Medical Disclaimer

To participate in ministries of the Urban Scholastic Center (hereafter referred to as The USC), I (the parent/guardian) hold harmless and release USC, its directors, officers, employees, volunteers and agents from liability for any fault, mistake, negligence, or omission causing damage, loss, injury, or bodily injury to me or my child arising from participation with USC, including any damage arising from the provision of emergency medical treatment. The terms of this Waiver are governed by the laws of the state of Kansas.

In the event I cannot be reached in a case of emergency, I hereby authorize USC, its officers, directors, agents, employees, or their designated medical professionals to make emergency medical decisions (i.e. doctors, hospitals, medical treatment, etc.) and/or to administer emergency medical assistance. I accept responsibility for payment of expenses incurred as a result of any medical treatment.

Medical Waiver Form 2020-2021

  • Electronic Signature* By typing my name here I understand that this constitutes a signature confirming that I acknowledge and agree to the above terms of the USC program