Medical History/check-Out Permission Form (Page 6 of 8) in pdf

PENINSULA FAMILY YMCA YOUTH PROGRAMS

8. LEGAL FEES. In the event of any controversy, claim or dispute between the parties arising

out of or relating to this agreement or the breach hereof or the activity, the prevailing party shall

RELEASE AGREEMENT

be entitled to recover from the losing party reasonable expenses, attorney fees and costs.

In consideration of the use of the property, facilities and/or services of the Peninsula Family

9. REPRESENTATIVES. The undersigned enters into this agreement for himself/herself,

YMCA Youth Programs, including any travel related thereto, the undersigned agrees as

heirs, assigns and legal representatives.

follows:

10. ACKNOWLEDGEMENT. The undersigned has read and understands this agreement and

1. RISK FACTORS. The undersigned understands and acknowledges that the activities of

realizes it relates to releasing valuable legal rights and does so freely and voluntarily.

wakeboarding, waterskiing, surfing, sailing, windsurfing, kayaking, rowing, marine science,

related water sports, beach activities, transportation during camp, and transportation before and

11. TOWER ACKNOWLEDGEMENT. For use of Nautique wakeboard boats with a

after camp by camp personnel involve risks such as but not limited to the following which

tower, I further understand this exposes the above named minor to the additional risks of a large

might result from the activity itself, the acts of others or the unavailability of emergency care;

wake and the possible serious injuries resulting from aerial or other maneuvers.

RISK OF PROPERTY DAMAGE, BODILY INJURY, and POSSIBLY DEATH.

2. ASSUMPTION OF RISK. The undersigned ASSUMES ALL RISKS WHICH ARE

___________________________________________________

__________________

FORESEEABLE AND INVOLVED WITH OR ARISING FROM THE ACTIVITY, including

NAME OF MINOR

AGE

without limitation those risks described in Section 1 above.

APPROVAL OF PARENT/LEGAL GUARDIAN ON BEHALF OF MINOR

3. SKILLS AND TRAINING. The undersigned acknowledges that the below named minor

has the skills, qualifications, physical ability and training necessary to complete such activity.

I am the parent and/or legal guardian of the above-named minor. I have read and

The undersigned agrees that if he or she has any questions as to what skills, qualifications or

understand the agreement and realize the agreement involves releasing valuable legal

training is necessary to properly participate in the activity, then they shall direct such

rights of the minor and myself. I agree to be bound by all of the terms of the

questions to Camp management.

agreement. I also give my consent to the participation in the activity by the minor. I

4. RELEASE. The undersigned RELEASES the State of California, Peninsula Family YMCA,

also give my consent for my child to be included in photographs, videos, slides, and

the YMCA of San Diego County, the Trustees of the California State Universities, San Diego

movies taken at the Center by students, staff, TV, Radio and/or other news media. I

State University, Regents of the University of California, the University of California San

understand that pictures become property of Associated Students of SDSU, and might

Diego, the Associated Students of San Diego State University and all of their officers,

appear in promotional materials, publications, and social media.

employees and agents (referred to below as the “RELEASED PARTIES”) and agrees NOT TO

SUE them on account of or in connection with any claims, causes of action, injuries, damages,

cost or expenses (referred to below as “CLAIMS”) arising out of the activity, including those

___________________________________________________

___________________

based on the risks described in Section 1, whether or not caused by the negligence or other fault

SIGNATURE OF PARENT AND/OR LEGAL GUARDIAN

DATE

of the RELEASED PARTIES.

IF PERSON PARTICIPATING IS UNDER 18

5. WAIVER. The undersigned waives the protection provided by any statute or law in any

jurisdiction including California Code section 1542 whose purpose, substances and/or effect is

ARENT OR LEGAL GUARDIAN EMERGENCY TREATMENT CONSENT

to provide them a general release shall not extend to claims, material or otherwise which the

persons giving the release does not know or suspect to exist at the time of executing the release.

As the parent and/or legal guardian, I agree to the participation by the minor in the subject

This means, in part, that the undersigned is releasing unknown future claims.

activity. The undersigned hereby gives consent to medical treatment of the minor in case of an

emergency.

6. INDEMNIFY AND DEFEND. The undersigned agrees to INDEMNIFY AND DEFEND

the RELEASED PARTIES against, and hold them harmless from, any and all CLAIMS,

___________________________________________________

including attorney fees, which in any way arise from the activity which is the subject of this

SIGNATURE OF PARENT AND/OR LEGAL GUARDIAN

agreement and which include but are not limited to those risks described in Section 1 including

IF PERSON PARTICIPATING IS UNDER 18

any liability arising from the act or negligent act of the RELEASED PARTIES, the below

named minor or anyone else.

THIS FROM MUST BE RETURNED TO THE MISSION BAY YOUTH PROGRAMS OFFICE BEFORE

YOUR CHILD CAN PARTICIPATE IN THE YOUTH ACTIVITIES. IF THIS FROM IS NOT ON FILE

7. PAY. The undersigned agrees to pay for any and all damages to any property of the

IN THE YOUTH PROGRAM OFFICE, YOUR CHILD WILL NOT BE ALLOWED TO PARTICIPATE

RELEASED PARTIES caused by the undersigned whether negligently, willfully or otherwise.

UNTIL THE PARENT OR LEGAL GUARDIAN SIGNS FOR THEM. THIS FORM MAY NOT BE

EDITED OR CHANGED IN ANY WAY. IF YOU HAVE ANY QUESTIONS REGARDING THIS

RELEASE FORM, PLEASE CONTACT THE YOUTH PROGRAM DIRECTOR AT (858) 539-2003.

Medical History/check-Out Permission Form Page 6

Related Articles

Related forms

Related Categories