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Microsoft Word ASYMCA & TRVEA Release of Liability Form With DEPOSIT Western Day 2011
Microsoft Word ASYMCA & TRVEA Release of Liability Form With DEPOSIT Western Day 2011
Microsoft Word ASYMCA & TRVEA Release of Liability Form With DEPOSIT Western Day 2011
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 2011 Western Day on May 22nd. To confirm
your child’s participation, this registration form and a non-refundable twenty dollar deposit (cash/or check only) must be
submitted to the Armed Services YMCA at 3293 Santo Rd, San Diego, CA, 92124 by May16, 2011.
Each non-refundable deposit will be processed upon completion of registration. Should the family fail to attend the
program, the family can be placed on the ASYMCA ineligible service list.
****Parent/Guardian (Signature)____________________________________Date___________________****