REACH AYC Participation Waiver
WAIVER, RELEASE OF LIABILITY, ASSUMPTION OF RISK AND CONSENT TO USE IMAGE
This form must be completed and signed by all individual members who will be participating in any program, class, project, or activity at the REACH Ashland Youth Center and their parents or legal guardians, if the Member, (printed name), is under 18 years of age. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, hereby forever RELEASE(S) AND DISCHARGE(S) the County of Alameda (“County”), its employees, elected officials and agents, from any and all liabilities, claims, demands or causes of action that the above-named Member and/or his or her parent or legal guardian may hereafter have for any injuries and damages arising out of the participation in any program, class, outing, project, field trip or activity at any premises owned by the County (including the REACH Ashland Youth Center) or under the auspices of REACH Ashland Youth Center, including, but not limited to, losses caused by the passive or active negligence of the County or hidden, latent, or obvious defects in the premises or equipment used. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, understand(s) and acknowledge(s) that certain off site and on site activities at the REACH Ashland Youth Center (or under its auspices) involving physical activity, agility and contact, have inherent dangers that no amount of care, caution, instruction or expertise can eliminate. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, do(es) hereby expressly and voluntarily assume any and all risk of death and/or personal injury, which may be sustained while participating in any activities including the risk of passive or active negligence of the County, or latent or hidden or obvious defects in the premises or equipment used. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, acknowledge(s) having been given the opportunity (a) to read this entire document, and (b) to have it reviewed by an attorney. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, is/are signing this document voluntarily with a full understanding that by signing it the above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, do hereby release the County, its elected officials, its employees and agents from all liability resulting from my participation in any activities at the REACH Ashland Youth Center. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on ALL heirs and assigns of the Member. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, agree(s) to assume all responsibility for any property damage or injury to any person caused by me or my child while participating in any program and/or off site and on site activity at the REACH Ashland Youth Center. The County is not responsible for the loss or theft of any personal property that the Member may bring to REACH Ashland Youth Center or off-site activity. Members are strongly encouraged not to bring anything of value. The above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, understand(s) the importance of using images and sound recordings of REACH Ashland Youth Center’s activities in printed materials, websites, videos, film, and television broadcasts. Therefore, the above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age, give(s) permission for REACH Ashland Youth Center and its program affiliates to use photographs, video recordings, and voice recordings of the above-named Member free of charge. This consent includes the storage, retrieval, and reproduction of information or images. Photographs, videos, audio recordings and the tapes, negatives, and digital media from which images and sound recordings are made, shall be the property of REACH Ashland Youth Center, which shall have the right to publish, reproduce, distribute, and make other uses free of all claims on the part of the above-named Member and his or her parent or legal guardian, if the Member is under 18 years of age.
AUTHORIZATION TO TREAT A MINOR
I, the parent or legal guardian, of the child listed above, do hereby authorize and consent to any X-ray examination, anesthetic, medical, or surgical treatment rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act or a Dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital or emergency care facility holding a current license to operate a hospital or emergency care facility from the State of California Department of Public Health. I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power to render care which the aforementioned physician, in the exercise of his/her best judgment, may deem advisable for my child. Further, I understand my child will be participating in inherently dangerous activities and agree to pay for my child’s medical expenses. I understand that all effort shall be made to contact me prior to rendering treatment to my child, but any of the above treatment will not be withheld if I cannot be reached. This authorization is given pursuant to the provisions of the California Civil Code. This consent shall remain in effect until 31 December of the subject year.
By entering my full name below, I acknowledge that I have read, understand and approve the AUTHORIZATION TO TREAT A MINOR (with any restrictions I may have listed above), RELEASE FROM LIABILITY and the VIDEO-PHOTO RELEASE.
Have questions or need assistance?
Please call the REACH Front Desk at (510) 481-4551
