Address, City, State,Zip:
Activity/Program Participating In:
Child's Medical Information:
Please indicate all child's allergies, medications, physical limitations and any other pertinent information.
I give my permission for my child's photo to be used within (check all that apply)
Youth Fitness Center/Club General UseAthletic Club General UseClub Advertising and/or WebsiteI Do NOT Give Permission for my child's photo to be taken or used for any reason
Emergency Contact #1 Name:
Emergency Contact #1 Relation to Child:
Emergency Contact #1 Phone Number:
Emergency Contact #2 Name:
Emergency Contact #2 Relation to Child:
Emergency Contact #2 Phone Number:
Assumption of Risk: I, the undersigned, understand that activities and programs sponsored by the Clubs at River City involve physical activity, that accidents can occur during those activities and programs, and that participants in this or any physical activity can suffer injury or death. I, ON BEHALF OF THE ABOVE MENTIONED MINOR AND FOR MYSELF, HEREBY ASSUME THESE RISKS or PARTICIPATING IN THE ABOVE-MENTIONED ACTIVITY.
Release and Waiver: I return for allowing the Minor to participate, I, on behalf of Minor and for myself, hereby waive, release, and discharge the Clubs at River City, its shareholders, directors, officers, employees, representatives, agents, and successors and assigns for any and all loss, claims, injury, damage or liability which may arise while in, upon, or about the premises or the Clubs at River City or as a result of Minor's participation in any YFC activity.
Medical Treatment: In the event of an emergency, I authorize the Clubs at River City staff to administer first aid or CPR if needed or to secure from any licensed hospital, physician, and/or medical personnel or good Samaritan first aid providers, any treatment deemed necessary for my immediate care and agree that I will be responsible for payment of any and all medical services rendered.
I do hereby release and forever discharge the Clubs at River City from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with the volunteer's activities with the Clubs at River City.
Other: I give permission for my child to participate in the YFC planned activities. I accept full responsibility for my child's behavior and understand that if my child's behavior is violent or inappropriate that my child may be sent home and I will not receive a refund.
I have read and fully understand this Waiver of Liability.
By clicking "submit" below, you are electronically signing this Waiver of Liability.