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____________Age______Gender______
Name_______________________________________________Date of Birth____________Age______Gender______
Name_______________________________________________Date of Birth____________Age______Gender______
Name_______________________________________________Date of Birth____________Age______Gender______
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Activity or Group______Pin Pals Junior Links_________________________Date(s)__April 17 to June 5 __________
Location__________River Walk Golf Course____________________________________________________________

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 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.

****Parent/Guardian (Signature)____________________________________Date___________________****