Youth and Community Outreach Department

Release of Liability Form: Adults and Minors

Parent/Guardian Name(s) (print)______________________________________________________________________

Date(s) of Birth (same order)_________________________________________________________________________

Address___________________________________________Email__________________________________________

Home Phone__________________________Work__________________________Cell__________________________

Emergency Contact________________________________________________________________________________

EC Home Phone_______________________EC Work_______________________EC Cell_______________________

Minor Children Participating:

Name______________________________________________________________Age__________________________

Name______________________________________________________________Age__________________________

Name______________________________________________________________Age__________________________

Activity or Group____________________________________________________Date(s)________________________

Location_________________________________________________________________________________________

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. The minor is physically able
and mentally prepared to participate in all activities as described in the announcement for the program. I hereby
voluntarily and knowingly 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 by 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 rendered at the office of the physician or at the hospital. I understand that
the San Diego Armed Services 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, officers and directors thereof, any claim presently known or unknown for damage to
property or personal injury whether caused by equipment or the acts or omissions of others including San Diego
Armed Services YMCA personnel.

My Child(ren) will _____ Walk Home _____Be picked up. Person(s) who may pick up child(ren)____________________

_______YES My child(ren) can receive a healthy snack _______NO My child(ren) cannot receive a healthy snack

Food Allergies, if any:______________________________________________________________________________

****Parent/Guardian (Signature)____________________________________Date___________________****

I hereby grant full permission 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.

****Parent/Guardian (Signature)____________________________________Date___________________****