beaver lake release

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 Youth and Community Outreach Department Release of L iability For m: Adults and Minors Parent/Guardian Name(s) (print)______________________________________________________________________ Parents Date(s) of Birth (same order)__________________________________________________________________ Address  ________________________________ City  _________________ Zip____________Mili tary Housing? Yes/No Email Address  ________________________________________ Service Branch  _____________________ Rank_____  _ Home Phone  __________________________ Work  __________________________ Cell  __________________________ Emergency Contact  ________________________________________________________________________________ EC Home Phone  _______________________ EC Work  _______________________ EC Cell  _______________________ Minor Children Participating: Name  _______________________________________________ Date of Birth  _______________ Age  ___________ Name  _______________________________________________ Date of Birth  _______________ Age  ___________ Name  _______________________________________________ Date of Birth  _______________ Age  ___________ Name  _______________________________________________ Date of Birth  _______________ Age  ___________ Activity or Group: Father/Chi ld Fishing Trip at Beaver Lake  Date(s): April 3 rd , 2010 Location:  Mataguay Scout Reservation , 27955 Hwy 79, Santa Ysabel, CA, 92070. I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for the minor to participate in the San Di ego Armed Services YMCA pr ogram described above. I grant full permissi on 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 men tally prepared to participate in all act ivities as described in the announcement for the program. I hereby voluntarily and knowingl y 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 b y 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 rendere d at the office of the physician or at the hospital. I understand that the San Diego Armed Services YMCA i s not responsible for costs incurred for medi cal 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 o r 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 Fishing Trip at Beaver Lake. To confirm your family’s participation, registr ation forms and a refundable twenty dollar deposit (cash/or check only) must be submitted to the Armed Services YMCA at 3293 Santo Rd, San Diego, CA, 92124. Each refundable deposit wil l be available for return to parent signing below upo n check in at camp. Should the family fail to cancel their family’s space at least two weeks prior to the outing or the family not attend camp, or violate the rules outlined, the deposit will be considered a donation to the non profit Armed Services YMCA. ****Parent/Guardian (Signature)____________________________________ Date  ___________________**** OFFICE USE ONLY: COMPLETE UPON RETURN OF DEPOSIT  _ _4 /3 /1 0_ _ Date Deposit Returned Parent Signature Please accept my family’s twenty dollar deposit as a donation to the non profit Armed Services YMCA: Parent Signature: ______ 

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 Youth and Community Outreach DepartmentRelease of Liability Form: Adults and Minors

Parent/Guardian Name(s) (print)______________________________________________________________________ 

Parents Date(s) of Birth (same order)__________________________________________________________________ 

Address ________________________________ City _________________ Zip____________Military Housing? Yes/No

Email Address ________________________________________ Service Branch _____________________ Rank_____  _ 

Home Phone __________________________ Work __________________________ Cell __________________________ 

Emergency Contact ________________________________________________________________________________ 

EC Home Phone _______________________ EC Work _______________________ EC Cell _______________________ 

Minor Children Participating:

Name _______________________________________________ Date of Birth _______________ Age ___________ 

Name _______________________________________________ Date of Birth _______________ Age ___________ 

Name _______________________________________________ Date of Birth _______________ Age ___________ 

Name _______________________________________________ Date of Birth _______________ Age ___________ 

Activity or Group: Father/Child Fishing Trip at Beaver Lake   Date(s): April 3rd, 2010

Location: Mataguay Scout Reservation, 27955 Hwy 79, Santa Ysabel, CA, 92070.

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 childand/or myself to be photographed by the San Diego Armed Services YMCA staff for any legitimate purpose withoutpayment or compensation. The minor is physically able and mentally prepared to participate in all activities as describedin the announcement for the program. I hereby voluntarily and knowingly assume all risks and dangers inherent andincidental to the activities of the program. I will not hold the San Diego Armed Service YMCA liable for any injuriesincurred during the program or while my child(ren) is/are in transit to and from the program whether caused by equipmentor the act or omissions of others excepting damage or injury solely caused by the willful misconduct or negligence of theSan 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 theminors, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care whichis deemed advisable by, and is to be rendered under general or special supervision of, any physician and surgeonlicensed under the provisions of the California Medical Practice Act on the medical staff of any hospital, whether suchdiagnosis or treatment is rendered at the office of the physician or at the hospital. I understand that the San Diego ArmedServices 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, officersand directors thereof, any claim presently known or unknown for damage to property or personal injury whether caused byequipment 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 Fishing Trip at Beaver Lake. To confirm your family’s participation, registration forms and a refundable twenty dollar deposit (cash/or check only) must be submitted tothe Armed Services YMCA at 3293 Santo Rd, San Diego, CA, 92124.

Each refundable deposit will be available for return to parent signing below upon check in at camp. Should the family failto cancel their family’s space at least two weeks prior to the outing or the family not attend camp, or violate the rulesoutlined, the deposit will be considered a donation to the non profit Armed Services YMCA.

****Parent/Guardian (Signature)____________________________________ Date ___________________****

OFFICE USE ONLY: COMPLETE UPON RETURN OF DEPOSIT

 ____4/3/10______________ _____________________________________ 

Date Deposit Returned Parent Signature

Please accept my family’s twenty dollar deposit as a donation to the non profit Armed Services YMCA:

Parent Signature: _________________________________________________________