Oaklands Community Association Youth Programs Participant Information Form
Email address *
Participant
Date *
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YYYY
Program Name *
Participant Name *
Your answer
Date of Birth *
MM
/
DD
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YYYY
Address *
Your answer
Postal Code *
Your answer
Care Card Number *
Your answer
Emergency Contact
Parent/Guardian Name *
Your answer
Relationship to Participant *
Phone number (personal) *
Your answer
Phone number (work)
Your answer
Home email *
Your answer
Emergency Contact (other than above) *
Your answer
Relationship to Participant *
Your answer
Phone number (personal) *
Your answer
Phone number (work) *
Your answer
Special Information
Describe any physical limitations, allergies, medical conditions or medications required *
Your answer
Out Trip Permission
Some programs may include travel offsite. Parents/guardians will be informed of all offsite activities prior to the out trip. I hereby give permission for my child to go on supervised out trips with Oaklands Community Association staff and/or volunteers. *
Child Release
My child has permission to walk home after the program.
If no, I hereby authorize the following people to pick up my child from the program in the event that the parent(s)/guardian(s) listed above are unable to. Please provide full name(s) and phone numbers(s). *
Your answer
Photo Release
I give content for my child's picture to be taken for publicity or program advertising purposes.
Informed Consent
I acknowledge that there are risks associated with participation in any physical training, exercise, sports, adventure or activity. I have informed myself and understand the risks associated with my child’s participation in the program and (where applicable) my child’s use of the facilities, including the risk of personal injury, and freely accept these risks. I am also aware that there are additional risks in traveling to and from locations where activities are taking place, and freely accept those risks for my child. I acknowledge that program staff or volunteers may limit my child’s access to the program or facilities in the event of any misuse of the facilities or misconduct. In consideration of the permission granted to the child participant to participate in the program: 1. I hereby release and forever hold harmless, Oaklands Community Association (“OCA”), its volunteers, employees, contract instructors and agents or representatives from all claims and legal actions arising from personal injury or property damage or loss which I or the child participant may have or suffer as a result of the child’s participation in the program. 2. I agree that I am responsible for all costs of rescues or medical attention rendered to the child participant, or for the benefit of the participant arising from participation in the program, and I shall indemnify OCA from any and all liability in respect of any and all such costs. 3. I shall indemnify, and forever hold harmless, OCA, its volunteers, employees, contractor instructors and agents, from any and all liability for any damage to property or personal injury suffered by any third party resulting from the child’s participation in the program. 4. The release and waiver contained in this form are binding upon my heirs and executors. *
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Please enter your first and last name.
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