KIDZ CARE
JUNIOR CIVIC ASSOCIATION
Name: ____________________________________________
Parent/guardian: ____________________________________________
DOB: ____________________________________________
Address: ____________________________________________
City/State/Zip: ____________________________________________
Home tel.:
____________________________________________
Telephone/ Email: ____________________________________________
Cell phone:
____________________________________________
Email:
____________________________________________
Additional
Parent info:
Parent/guardian:
____________________________________________
Emergency Contact
Info:
Address: _________________________________________________
City/state/zip:
_________________________________________________
Home tel.: _________________________________________________
Cell phone: _________________________________________________
Email: _________________________________________________
Please list allergies to
food/medicine below:
_____________________________________________________________
I and we have fully read the entire document on the reverse
and agree to all its terms
and understand that it affects and gives up substantial
legal rights of myself and my wards.
I and we agree that we and our wards will be bound fully by
same.
Date: _____________
Signature of Parent/Guardian:
______________________________
Print Name: _________________________________
Disclosure
Notice
I Parental Permission- The undersigned
parent/guardian herby gives permission for my daughter/son/ward to
attend and
participate in events sponsored/organized by Kids Care Junior Civic
Association, Inc. I hereby
acknowledge that
by attending said events there is a possibility of physical illness or injury
to my daughter/son/ward
and I do hereby
waive, release and discharge any claims for injury, which may arise against
Kidz Care Junior Civic
Association, Inc.,
its directors, members, agents and servants.
Permission is granted to use my daughter/son/ward’s
picture in future
advertisement and literature for Kidz Care Junior Civic Association, Inc. and
events sponsored and/or
conducted by
it. Permission is hereby granted to any
licensed nurse or physician of the State of New York to
administer medical
assistance to my ward or child in an emergency when necessary if I am not
present to provide such
consent personally.
II Promise to
Maintain Insurance- I (the applicant and undersigned parent or guardian)
hereby acknowledge
that Kidz Care
Junior Civic Association, Inc. (“The Association”) does not maintain medical
insurance for the
benefit of members
or participants. I understand and agree
that maintenance of the member’s own medical
insurance coverage
is a requirement of and condition to membership in The Association and to
participation in
the activities of
The Association. I warrant and represent that medical insurance coverage will
be maintained by
the
member/parents/guardians in force at all times during which the member remains
a member of or participant
in the activities
or operations of The Association. I
understand that these statements are important statements
upon which The
Association should and will rely.
III Assumption of
Risk/Hold Harmless, Waiver and Release-
The member and the
Member’s parents/guardians assume all the risks of participating in the
activities of Kidz Care
Junior Civic
Association, Inc. to the fullest extent
permitted by law, I (the undersigned parent or guardian) hereby
undertake, warrant
and agree to defend, indemnify and hold harmless Kidz Care Junior Civic
Association
(“The
Association”), its officers, directors, members, employees, sponsors, donors,
supporters, volunteers, agents,
and servants
(hereinafter “releasees”) from and against all liability, suits, damages,
costs, (including court costs, defense
and attorney
fees), claims, controversies, and causes of action for or arising out of bodily
injury to or damage to
property of me
and/or to the Member, and/or to the Member’s household, family, siblings,
parents, and/or guardians.
I hereby release
discharge and promise not to sue the releasee(s) in connection with any/all
liability or rights of recovery
to me, and /or to
my heirs, next of kin or representative, arising from claims of negligence, or
arising from incidents of
property damage or
bodily injury or death, and all resulting damages including social and economic
injury, whether
caused by the
negligence or fault of the releasee(s) or otherwise. I waive any and all rights to sue or recover or to make
claim in
connection with the same. I intend that
the releasee(s) shall hereby be and are relieved from the ordinary
responsibility for
the consequences of their actions, inaction, fault or neglect, other than for
the gross negligence or
wanton
conduct. I make this waiver (meaning
this entire section 3) on behalf of myself, the member and/or any other
parents, guardians
or personal representatives of the Member, to be binding on all of them. This waiver may not be
modified in any
way. If any part of this waiver is
determined to be invalid by law, all other parts of this waiver shall
remain valid and enforceable.