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___________ Name_______________________________________________Date of Birth_______________Age___________ Name_______________________________________________Date of Birth_______________Age___________ Name_______________________________________________Date of Birth_______________Age___________ Activity or Group: Father/Child Fishing Trip at Beaver Lake Date(s): April 3rd, 2010 Location: Mataguay Scout Reservation, 27955 Hwy 79, Santa Ysabel, CA, 92070. 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___________________****
The San Diego Armed Services YMCA is pleased to invite your family to the Fishing Trip at Beaver Lake. To confirm your family’s participation, registration forms and a refundable twenty dollar deposit (cash/or check only) must be submitted to the Armed Services YMCA at 3293 Santo Rd, San Diego, CA, 92124. Each refundable deposit will be available for return to parent signing below upon check in at camp. Should the family fail to cancel their family’s space at least two weeks prior to the outing or the family not attend camp, or violate the rules outlined, the deposit will be considered a donation to the non profit Armed Services YMCA.

****Parent/Guardian (Signature)____________________________________Date___________________**** OFFICE USE ONLY: COMPLETE UPON RETURN OF DEPOSIT ____4/3/10______________ Date Deposit Returned _____________________________________ Parent Signature

Please accept my family’s twenty dollar deposit as a donation to the non profit Armed Services YMCA: Parent Signature: _________________________________________________________