PARK 'n IT | Health Form and Waiver

Parent/Guardian Authorization Agreement:

This health history is correct to the best of my knowledge, and the person herein has permission to engage in all prescribed program activities. In the case of emergency in which I am not able to give permission for medical treatment and my designated emergency contact cannot be reached, I authorize the staff or agents of the district to obtain whatever medical treatment is deemed necessary for my child's welfare. In the case of my child, this authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether
my medical insurance would cover such charges or fees.

By submitting this online form, I, the undersigned (submitter), as participant, or as parent or legal guardian of the child listed on this form, hereby assume full responsibility for all risk of injury or loss which may result from my or my child' participation in the program listed below, and hereby agree to hold harmless, release and forever discharge The East Bay Regional Park District, it's officers, directors, agents, and employees (collectively "District") and their representatives, from any and all claims and demands whatsoever which the undersigned, and any of them or any third party and their representatives or any person acting under persons, or damage to, loss of or destruction of property arising or resulting directly or indirectly from my or my child's participation in the aforementioned activity, and occurring said participation, or anytime subsequent thereto regardless of whether said claims or demands arise out of negligence on the part of the District. The terms 'of this release shall serve as a release and assumption of risk for myself, my child, heirs, executives, administrators, and for all of my family members. I understand, agree, and acknowledge that some activities in this program may be hazardous nature and/or include physical and/or strenuous activity.

I hereby assume all risk of such activities. Understanding this, I state to the best of my knowledge that I or my child listed on this form have no medical, physical, mental, or emotional health conditions which would hinder my or my child's active participation in the program listed on this form. In the case of any emergency in which I am not able to give permission for medical treatment and my designated emergency contact cannot be reached, I authorize the staff or agents of the District to obtain whatever medical treatment is deemed necessary for my child's welfare. In the case of my child, this authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether my medical insurance would cover such charges and fees. I give my full permission to East Bay Regional Park District and any other media sources to use my or my child's name and any photographs, video graphs, motion pictures, or recordings for any publicity and promotional purposes without obligation or liability to me.

PARK 'n IT | Health Form and Waiver

CHILD INFORMATION





SWIMMING

Yes, my child may go in the water with staff supervision.
No, I do not want my child to go in the water at all.

WEEK(S) ARE YOU SIGNING UP FOR?

June 11-15: Temescal, Oakland
June 18-22: Temescal, Oakland
June 25-29: Don Castro, Hayward
July 9-13, Contra Loma, Antioch
July 16-20, Coyote Hills, Fremont
July 23-27 Miller Knox, Richmond
July 30-August 3: Ardenwood, Fremont

PARENT / GUARDIAN NO.1 INFORMATION









PARENT / GUARDIAN NO.2 INFORMATION








IN ADDITION TO THE PARENT/GUARDIAN, PLEASE LIST 2 MORE EMERGENCY CONTACTS:







IN ADDITION TO THE PARENT/GUARDIAN, WHO IS AUTHORIZED TO PICK UP THE CAMPER? (PHOTO I.D. REQUIRED AT PICK-UP)










CHILD MEDICAL HISTORY

Yes
No





Yes

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