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Member Info

   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.