Youth and Community Outreach Department

Release of Liability Form: Adults and Minors

Parent/Guardian Name(s) (print)______________________________________________________________________

Parents Date(s) of Birth (same order)__________________________________________________________________
Address________________________________City_________________Zip____________Military Housing? Yes/No
Email 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___________________
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Activity or Group________Camp Hero and YES! __________________________Date(s) August 2 to August 26
Location_Armed Services YMCA Paul Hartly Complex 3293 Santo Road San Diego Ca, 92124_____________________

I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for the
minor to participate in the San Diego Armed Services YMCA program described above. I hereby grant full
permission for my child and/or myself to be photographed by the San Diego Armed Services YMCA staff for any
legitimate purpose without payment or compensation. The minor is physically able and mentally prepared to
participate in all activities as described in the announcement for the program. I hereby voluntarily and knowingly
assume all risks and dangers inherent and incidental to the activities of the program. I will not hold the San Diego
Armed Service YMCA liable for any injuries incurred during the program or while my child(ren) is/are in transit to and
from the program whether caused by equipment or the act or omissions of others excepting damage or injury solely
caused by the willful misconduct or negligence of the San Diego Armed Services YMCA, 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 to
the minors, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital
care which is deemed advisable by, and is to be rendered under general or special supervision of, any physician
and 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 that
the San Diego Armed Services YMCA is not responsible for costs incurred for medical care. If I participate in the
program, whether as coach, instructor, aide, spectator, or participant, I presently waive as to the San Diego Armed
Services YMCA and staff, officers and directors thereof, any claim presently known or unknown for damage to
property or personal injury whether caused by equipment or the acts or omissions of others including San Diego
Armed Services YMCA personnel.

_______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___________________****