Youth and Community Outreach Department

Release 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___________________
Name______________________________________________________________Date of Birth___________________
Name______________________________________________________________Date of Birth___________________
Activity or Group_____ASYMCA & Kids Korps Bike Giveaway_________________ Date(s) ___December 10, 2010___
Location_______ASYMCA HQ 3293 Santo Road San Diego CA 92124_______________________________________

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 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. 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.

****Parent/Guardian (Signature)____________________________________Date___________________****
 RELEASE AND WAIVER OF LIABILITY AGREEMENT

Note: Your registration will NOT be processed unless this waiver is signed and dated prior to participation.

I, _____________________________________ (“Recipient”), acknowledge that I

have voluntarily applied for my (*parent or guardian) child to participate in “Party
with a Purpose” /Build-a-Bike event coordinated by Kids Korps USA and held at
the Armed Services YMCA at 3293 Santo Road in San Diego. As part of my
participation in this event, he/she will receive a new youth bicycle and bicycle
helmet.

I understand that riding a bicycle can be dangerous. I understand that cyclists

should follow all the Rules of the Road as a vehicle should do. I also understand that
a properly fitted helmet should be worn at all times when riding a bicycle. I
knowingly and freely assume all such risks, both known and unknown, and assume
full responsibility for my child’s participation.

I verify this statement by placing my initials here: __________________

I, for myself and on the behalf of my heirs, assigns, personal representatives and
next of kin, hereby release and hold harmless KIDS KORPS USA, their officers,
officials, agents and/or employees, volunteers, staff, other participants, sponsoring
agencies, sponsors, advertisers, and if applicable, owners and lessors of premises
used to conduct the event ("Releases"), with respect to any and all injury, disability,
death or loss or damage to person or property. I have read this release of liability
and assumption of risk agreement, fully understand its terms, understand that I
have given up substantial rights by signing it, and sign it freely and voluntarily of
my own free will.

As Parent or Guardian, I verify that the dangers if the activity and the significance
of this Release and Waiver were explained to us and that we have fully understood
them.

Executed at ______________________, California on ______________, 2010.

PARENT OR GUARDIAN
__________________________
signature
ADDRESS:_________________________
_________________________