Child Care Provider Agreement, Medical Release, And Liability Waiver Form
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1Lake Shore Yacht & Country Club
6777 Lake Shore Road
Cicero, New York 13039
Child Care Provider Agreement,
Medical Release, and Liability Waiver
Child’s Name
Address
City
State
Zip
Emerg. Contact
Phone
Relationship
Physician
Phone
Insurance Information
*IMPORTANT MUST READ*
I, the Parent/Guardian of the registrant, a minor, am a member of Lake Shore Yacht & Country Club, Inc. (“LSYCC”), agree that the
registrant and I will abide by the rules of LSYCC and sponsors; recognizing the possibility of physical injury associated use of the
pool and land areas.
I, the Parent/Guardian of ______________________, minor child do hereby give my permission to have ______________________
as a responsible child care provider monitor the activities of _____________________________ at the pool and related areas at
LSYCC. I agree to be responsible for any charges incurred for the benefit of _________________ and/or ___________________ at
the pool, Club House, or related areas for goods, services, etc. provided.
I hereby release, discharge, and/or otherwise indemnify LSYCC, its affiliated organizations and sponsors, their employees, and
associated personnel, including lifeguards, against any claim by or on behalf of the registrant’s and/or child care provider’s use of the
facilities and/or participation in related activities on the premises.
Parent/Guardian’s Name (Print) ___________
__________
Member #________
Parent/Guardian’s Signature ___
_________________________
Date ___
Registrant’s Signature (18 & Over) ________
__________________
Date _____________
Consent for Medical Treatment (Minor)
As the Parent/Guardian of the registrant, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor or
Medicine Doctor of Dentistry. This care may be given under whatever conditions necessary to preserve the life, limb, or well being of
the registrant.
Parent/Guardian’s Signature ___
_________________________
Date ___
Address
City
State
Zip
Phone
_______________________________ (home)
_______________________________ (cell)
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