Youth and Community Outreach Department Release of Liability Form: Adults and Minors

Parent/Guardian Name(s) (print)______________________________________________________________________ Parents Date(s) of Birth (same order)__________________________________________________________________ Email Address________________________________________Service Branch_____________________Rank______ Home Phone__________________________Work__________________________Cell__________________________ Emergency Contact________________________________________________________________________________ EC Home Phone_______________________EC Work_______________________EC Cell_______________________ Minor Child Participating: Name_____________________________________________Date of Birth___________________Gender___________

OFFICE USE ONLY: YES! Youth 2011 Selected Outing Date(s):

Camp Surf August 4th August 18th Waitlist Waitlist

Horseback Riding August 11th August 25th Waitlist Waitlist

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:______________________________________________________________________________ My Child(ren) will _____ Walk Home _____Be picked up. Person(s) who may pick up child(ren)____________________

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