PARK 'n IT | Health Form and Waiver

Parent/Guardian Authorization Agreement:

*Note: Due to the Covid-19 global pandemic, at home health screening needs to begin 2 weeks prior to the beginning
of camp. Daily temperature taking and symptomatic observations beginning July 12th and culminating July 30th are
mandatory for admittance to camp. Information to follow in the Parent Info Letter.

Because of COVID-19, both Youth and Guardian must agree to all of the following*:

  • Youth agrees to bring and wear a mask at all times during this program
  • Youth agrees to remain 6 ft apart from all other program participants
  • Guardian agrees to check the temperature of the youth every morning before coming to the program, and to ask if:
      Youth is experiencing a new cough, sore throat, or shortness of breath
  • Guardian agrees to keep Youth at home if Youth is experiencing high temperatures or symptoms

* These guidelines are from the “Novel Coronavirus (COVID-19) Alameda County Public Health Department Guidance and FAQ for Camps and Youth Extracurricular Programs, June 12, 2020” issued by the Alameda County Health Care Services Agency Public Health Department.

I hereby acknowledge that the novel coronavirus, COVID19, is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and health agencies recommend social distancing and have, in many locations, prohibit the congregation of groups of people. I acknowledge and agree that the East Bay Regional Park District is directing all individuals that participate in the Adventure Crew program activities to conduct the activities in compliance with the applicable Federal, State, County and local health orders. Further, any participant recognizes that it is their own responsibility to ensure compliance with all applicable orders. Further, I acknowledge and understand that the East Bay Regional Park District does not and cannot guarantee that any participants will not become infected with COVID-19 or any illness or injury while participating in the planned activities. I hereby release, covenant not to sue, discharge, and hold harmless the East Bay Regional Park District, its Board of Directors, officers, employees, agents, defend and representatives from any claims, including all liabilities, actions, damages, costs or expenses of any kind arising out of or relating to the planned activities including but not limited to any illness, death, and loss of any kind by participating in planned activities related to COVID-19 or any illness or injury. I understand and agree to release and assumption of risk includes any claims based on the actions, omissions, or negligence of East Bay Regional Park District, its Board of Directors, officers, employees, agents, and representatives, whether a COVID-19 infection occurs before, during,
or after participation in any activity.

WAIVER, RELEASE AND ASSUMPTION OF RISK / AUTHORIZATION FOR EMERGENCY TREATMENT
I, the undersigned (by submitting this online form), 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. This health history is correct to the best of my knowledge, and the person herein has permission to engage in all prescribed program activities.

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?

July 26-30: 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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