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: _________________________________________________________