Event - Summer Program Registration
Emergency Contact Name
Emergency Contact Phone
Relationship to Participant
Food & Other Allergies
General Physical Condition
Activities and Sports Involvement
I, the child(ren)’s parent and/or legal guardian represent that I understand the nature of the activities and that I am and the above named child(ren) are qualified, in good health, and in proper physical condition to participate in such activities. I acknowledge that if I believe any conditions are unsafe, I will immediately discontinue participation in such activities. I fully understand that the activities involve risks of serious bodily injury, including permanent disability, paralysis and death, which may be caused by my own or the above named child(ren)’s actions, inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the “Releasees” named below; and that there may be other risks either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, cost, and damages I or the above named child(ren) incur as a result of my or the above named child(ren)’s participation in the activities. I hereby release, discharge, and covenant not to sue summer program center, their respective administrators, shareholders, directors, agents, officers, managers, members, volunteers, and employees, other participants (the “Releasees”) from all liability, claims, demands, losses, or damages, on my account or the child(ren)’s account caused or alleged to be caused in whole or in part by the negligence or the Releasees orotherwise, including negligent rescue operations and further agree that if, despite this release, waiver of liability, and assumption of risk I, the child(ren) or anyone on my or the child(ren)’s behalf, makes a claim against any of the Releasees, I will defend, indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost, which any may incur as the result of such claim, including without limitation litigation expenses and attorneys’ fees. I hereby give permission to summer program center and the medical personnel selected by summer grogram center to order x-rays, routine tests, treatment and transportation for me and the above named child(ren). In the event I cannot be reached in an emergency, I hereby give permission to summer program center and the medical personnel selected by center to secure and administer treatment, including hospitalization, for me and the above named child(ren).
I hereby give my permission to have photographs or videos taken and used for the purpose of providing visual publicity for the summer program center.