Youth and Community Outreach DepartmentRelease of Liability Form: Adults and Minors
Parent/Guardian Name(s)
(print)______________________________________________________________________
Parents Date(s) of Birth
(same order)__________________________________________________________________
Address
________________________________
City
_________________
Zip____________Military Housing? Yes/NOEmail Address
________________________________________
Service Branch
_____________________
Rank_____
_
Home Phone
__________________________
Work
__________________________
Cell
__________________________
Emergency Contact
________________________________________________________________________________
EC Home Phone
_______________________
EC Work
_______________________
EC Cell
_______________________
Minor Children Participating:Name
______________________________________________________________
Date of Birth
___________________
Name
______________________________________________________________
Date of Birth
___________________
Name
______________________________________________________________
Date of Birth
___________________
Activity or Group
____________________________________________________
Date(s)_
_______________________
Location
_________________________________________________________________________________________
I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for theminor to participate in the San Diego Armed Services YMCA program described above. The minor is physically ableand mentally prepared to participate in all activities as described in the announcement for the program. I herebyvoluntarily and knowingly assume all risks and dangers inherent and incidental to the activities of the program. I willnot hold the San Diego Armed Service YMCA liable for any injuries incurred during the program or while mychild(ren) is/are in transit to and from the program whether caused by equipment or the act or omissions of othersexcepting damage or injury solely caused by the willful misconduct or negligence of the San Diego Armed ServicesYMCA, or its employees, volunteers, or agents.I do hereby authorize the San Diego Armed Services YMCA as agent for the undersigned, to consent with respect tothe minors, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospitalcare which is deemed advisable by, and is to be rendered under general or special supervision of, any physicianand surgeon licensed under the provisions of the California Medical Practice Act on the medical staff of any hospital,whether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand thatthe San Diego Armed Services YMCA is not responsible for costs incurred for medical care. If I participate in theprogram, whether as coach, instructor, aide, spectator, or participant, I presently waive as to the San Diego ArmedServices YMCA and staff, officers and directors thereof, any claim presently known or unknown for damage toproperty or personal injury whether caused by equipment or the acts or omissions of others including San DiegoArmed Services YMCA personnel.
My Child(ren) will _____
Walk Home _____Be picked up. Person(s) who may pick up child(ren)____________________ _______
YES
My child(ren) can receive a healthy snack _______
NO
My child(ren) cannot receive a healthy snack
Food Allergies, if any
:______________________________________________________________________________
****Parent/Guardian
(Signature)____________________________________
Date
___________________****
I hereby grant full permission for my child and/or myself to be photographed by the San Diego Armed Services YMCAstaff for any legitimate purpose without payment or compensation.
****Parent/Guardian
(Signature)____________________________________
Date
___________________****
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