KING HARBOR YOUTH FOUNDATION /
KING HARBOR YACHT CLUB
The
undersigned parents or legal guardians of ______________________ (“child”),
request that the child be allowed to participate in the King Harbor Youth
Foundation Race Team Program, associated events, and other junior sailor
activities (“activities”) which take place through 2007.
This
agreement shall remain in effect until the King Harbor Youth Foundation
receives written notice of cancellation of consent by mail or until the end of
the activities described above.
In
return for the child being permitted to take part in the activities and to use
the facilities and property of the King Harbor Youth Foundation and King Harbor
Yacht Club, each of us makes the following representations and warranties:
1.
I/We
are fully authorized to execute (sign) this Agreement.
2.
I/We
are familiar with the programs included in the activities, and I understand
officers and employees of King Harbor Youth Foundation and King Harbor Yacht
Club are available to discuss particular activities if I/We should desire
additional information. I/We also understand I/We am/are solely responsible for
the arrival and departure of my child at the beginning and end of each day's
activity. I will not allow my child to remain on the premises of King Harbor
Yacht Club or any location where any King Harbor Youth Foundation activity may
occur after each day's program without appropriate supervision or the written
permission of King Harbor Youth Foundation. I/We agree King Harbor Yacht Club
and King Harbor Youth Foundation have no responsibility for the supervision of
my child at times other than during the scheduled activities.
3.
I/We
will inform my child that he/she is expected to cooperate with, and follow the
directions of, the persons in charge of the activities and to act in a manner
consistent with the spirit of good sportsmanship and respect for the rights of
others, and agree that any failure of my/our child to do so shall be cause for
dismissal from any and all activities of or being participated in by King
Harbor Youth Foundation.
4.
My
child is in good health, and I know of no reason why he/she would be incapable
of participating in the activities. My child knows how
to swim. I will immediately notify the designated King Harbor Youth Foundation
or King Harbor Yacht club supervisor, if a change in my child's health or other
condition would affect my child's ability to participate in the activities.
WAIVER OF LIABILITY: I/We waive and release any rights I/we,
my/our heirs, distributees, guardians, legal representatives and assigns may
have or acquire to make a claim against, sue, attach the property of or
prosecute King Harbor Youth Foundation, King Harbor Yacht Club or any of its
members, directors, officers, instructors, agents, employees, assigns, and
affiliated organizations (hereafter referred to as "releasees") for
monetary damages caused by injury to my child or damage to the property of my
child or myself arising from my child's participation in the activities and use
of the facilities and property of King Harbor Youth Foundation and/or King
Harbor Yacht club, whether or not the injury or damage results from the
negligence or other action, except intentional acts of any of the releasees.
(Please initial to indicate you have read
this paragraph.) __________________.
5.
ASSUMPTION
OF RISK: I/We am/are aware
that the activities may involve maneuvering a boat, sailboard or other
watercraft on deep waters in potentially hazardous conditions which may
include, among other things, cold water, strong winds, high waves, ocean surge,
undercurrents and rip tides, sudden and unexpected immersion in deep waters and
collision with other watercraft or stationary objects such as docks, pilings
and buoys; the foregoing hazards may also be encountered while my/our child is
a passenger in watercraft being used for training, instructional, safety or
supervisory purposes. With knowledge of the dangers involved, I/We voluntarily
ask that the child be allowed to take part in the activities.
6.
I/WE
ACCEPT ANY AND ALL RISKS TO MYSELF/OURSELVES AND MY/OUR CHILD OF INJURY, DEATH
AND PROPERTY DAMAGE ARISING FROM PARTICIPATION IN THE ACTIVITIES AND THE USE OF
THE FACILITIES AND PROPERTY OF KING HARBOR YOUTH FOUNDATION AND/OR KING HARBOR
YACHT CLUB, WHETHER OR NOT CAUSED BY THE NEGLIGENCE OR OTHER ACTION EXCEPT
INTENTIONAL ACTS, OF ANY OF THE RELEASEES.
(Please initial to indicate you have read
this paragraph.) __________________.
7.
INDEMNITY
AGREEMENT: I/We agree to indemnify and hold the
releasees harmless from any loss, liability, damage or cost, including
reasonable attorneys’ fees, that may be incurred relating to my/our child's
participation in the activities of King Harbor Youth Foundation and/or King
Harbor Yacht Club whether or not such loss, liability, damage or cost results
from the negligence or other action, except intentional acts, of any of the
releasees.
(Please
initial to indicate you have read this paragraph.) __________________.
I/We
have carefully read this agreement and fully understand its contents. I/We
am/are aware the agreement includes a wavier of liability, an assumption of
risk and an agreement by me/us to indemnify the releasees, and sign it of
my/our own free will.
_______________ _____________ _______________________
Parent’s Signature Date Parent’s
Name (print)
_______________ _____________ _______________________
Parent’s Signature Date Parent’s
Name (print)
_______________ _____________ _______________________
Child’s Signature Date Child’s
Name (print)
KING HARBOR YACHT CLUB
TO WHOM IT MAY CONCERN:
The
undersigned hereby authorize the adult persons into whose care our child has
been entrusted, as part of the King Harbor Youth Foundation/King Harbor Yacht
Club, during the period ending through December 31, 2007, to consent on the
undersigned’s behalf to any X-ray examination, anesthetic, medical or surgical
treatment and hospital care to be rendered to said minor under general or
special supervision and upon the advice of a physician and surgeon licensed
under the provisions of the Medical Practice Act, or to consent to an X-ray
examination, anesthetic, dental or surgical diagnosis or treatment and hospital
care to be rendered to said minor by a dentist licensed under the provisions of
the Dental Practice Act.
It
is understood permission is also hereby granted to the agents of King Harbor
Youth Foundation/King Harbor Yacht Club and to the paramedics of the City of
Redondo Beach, County of Los Angeles (or of such other area as where my child
may be located during travel to or from or participation in any King Harbor
Youth Foundation activity) or such other government-licensed agency that may
have jurisdiction to obtain and administer such medical aid or assistance as
may, in their judgment, be required for the immediate care of our child in the
event such help of an emergency nature becomes necessary.
It
is understood that this authorization is given in advance of any specific
diagnosis, treatment, or hospital care being required but is given to provide
authority and power on the part of our aforesaid agent(s) to give specific
consent to any and all such immediate care, diagnosis, treatment or hospital
care which the aforementioned physician in the exercise of his best judgment
may deem advisable, and neither said agent or any organization involved assumes
any financial responsibility for exercising this action.
This
authorization is given pursuant to the provisions of Section 25.8 et seq. of
the Civil Code of California.
1. Family
Doctor Phone:
_____________________________________________________________________________________
2. Persons to contact in emergency: (please
designate two if possible)
_______________________________________________________________________________
_______________________________________________________________________________
3.
Medical
Problems:
_______________________________________________________________________________
_______________________________________________________________________________
4. Known
Allergies:
_______________________________________________________________________________
_______________________________________________________________________________
5. Hospital Insurance
_______________________________________________________________________________
_______________________________________________________________________________
In
no event shall King Harbor Youth Foundation, King Harbor Yacht Club, its
officers, directors, employees, instructors, agents, or assigns be liable for
any first aid treatment or hospital care rendered or drugs, medicine or
surgical procedures performed pursuant to this consent.
THIS AUTHORIZATION SHALL
REMAIN EFFECTIVE UNTIL REVOKED IN WRITING.
_______________ _____________ _______________________
Parent’s Signature Date Parent’s
Name (print)
_______________ _____________ _______________________
Parent’s Signature Date Parent’s
Name (print)
Address:
____________________________
____________________________
Work
Phone 1: _______________
Work
Phone 2: _______________
Home
Phone 1: _______________
Home
Phone 2: _______________