City Of White Plains Youth Bureau White Plains Youth Bureau Babysitter'S Training Participation Form (Page 5 of 5) in pdf

CITY OF WHITE PLAINS YOUTH BUREAU

September 2013 - June 2014

Release

Child=s Name:

Address:

D.O.B.:

Sex: M

In consideration of your acceptance of my child for his/her participation in the activities/programs of the City of White

Plains Youth Bureau, I agree that I am aware of the inherent dangers and risks involved in these activities/programs

including bodily injury which may result of strenuous activity or other causes related to these activities/programs. I

agree to release and hold harmless the City of White Plains, its officials, officers, agents, employees, and volunteers,

from and against any and all liability, damage or claim of any nature arising out of or in any way related to my child=s

participation in these activities/programs except those things caused by the sole negligence of the City. I understand

that the City of White Plains does not provide accident or medical insurance and I am financially responsible for any

and all medical expense whatsoever. I am advised to consult my child=s physician before allowing my child to

participate in any strenuous activity. I have read, understand and agree with the terms of this release.

Signature of Parent/Guardian: Date:

I, , as parent/guardian, hereby consent that the City of White Plains may

videotape/photograph my child, , and use the images/audio for

publication/broadcast/website. I waive any claim arising against the City of White Plains from the use of such

images/audio within or without the City or any other media.

I understand that the City of White Plains, its employees and volunteers act solely as an agent in arranging for transportation,

accommodations, and other services for special events and field trips. The City of White Plains does not assume, and in fact,

expressly disclaims, any liability for injury, illness, damage, loss, accident, or delay due to any act, negligence or default of the

event/trip guide, or any company or person engaged in transporting the passengers, or rendering any services or

accommodations, or carrying out the arrangements for any tour, or their agents, servants, and employees.

I understand that in case of serious injury or illness to my child, I authorize the City Youth Bureau representatives to transfer my

child to a hospital or other medical facility for treatment. A reasonable attempt to contact me or my child=s emergency contact

will be made. I accept responsibility for all costs involved in the medical transport and treatment of my child.

Signature of Parent/Guardian: Date:

City Of White Plains Youth Bureau White Plains Youth Bureau Babysitter'S Training Participation Form Page 5