Emergency Information, Indemnity & Consent Form

Required For Each Child In Any Youth Center Program


INDEMNITY AND HOLD HARMLESS AGREEMENT

I/we hereby grant permission for my child to participate in the Los Alamitos Youth Center, Inc. program for which I am registering. I agree to indemnify and hold harmless the Los Alamitos Youth Center, City of Los Alamitos, Los Alamitos Unified School District, Rossmoor Community Services District, the Applied Music Studio and any other entity associated with the program, their officers, agents and employees from any liability, claim or action arising out of such participation. I understand that this program is not bound by the responsibilities and legalities that accompany a licensed daycare program. I further certify that my child is in good health and has no physical or other impediment which would endanger him/her or any other participant in taking part in such an activity.

CONSENT FOR FIRST AID TREATMENT, TRANSPORTATION & PHOTOGRAPHIC RELEASE

I hereby authorize the staff of the Youth Center to provide immediate first aid to my child in the event of illness or injury. In addition, if this program provides for the transportation of my child, I hereby grant permission to the Youth Center to provide such transportation. Lastly, I hereby give the Los Alamitos Youth Center, Inc., it's successors and assigns, the absolute and irrevocable right and permission with respect to photographs, videos, motion pictures, and /or sound recordings being taken of my child: (a) to use, reuse, publish and republish in whole or in part and (b) to use my child's name. I further release the Youth Center from any claims and demands arising out of the use of same.


Gender:
M

F
Program:













Additional people who can pick my child/children up:

*ACKNOWLEDGEMENT*: By submitting this form, I have read, understand and agree to all the terms as set forth above. I also Authorize the designated individuals to pick up my child/children.



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