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YOUTH PERMISSION SLIP / HOLD HARMLESS AGREEMENT - Miraloma Teen Center

  1. Contact Information:
    vguerrero@anaheim.net

  2. Family Information

  3. Emergency Contact Information

    Parents/Guardians will not be accepted as emergency contacts.

  4. I understand that pictures/videos may be taken of me, my family and/or my children. I hereby assign and authorize the City of Anaheim the right (all rights) to such pictures/videos.  I also authorize the organizations, without limitation, the right to reproduce, copy, exhibit-publish (broadcast) or distribute any such picture/video, and waive any rights or claims I may have against the organizations and/or any of its affiliates, subsidiaries, or assignees except as outlined in this contract.



    We collect personal information directly from you for reasons that are discussed in our privacy statement.  We may be required to collect some personal information as mandated by law or as requested from organizations that fund this program.  A Privacy Notice is available upon request.

  5. has my permission to voluntarily participate in programs or activities run by the City of Anaheim, Anaheim Community Foundation, Anaheim Union High School District and Anaheim City School District (also referred to as ORGANIZATIONS).



    In consideration of the permission by the City of Anaheim to accept the above named participant(s) in the activity(ies) listed above given, taught or sponsored by the City, the undersigned hereby releases the City from and waives and relinquishes any claim, liability, cause of action, damages, or costs for personal injury or property damage arising as a result of participation in or receiving instructions from the City regarding said activity, excepting for such personal injury or property damage as may arise directly out of the active negligence of the City, its officers, agents or employees. The undersigned acknowledges that he/she has been fully advised of the risks and potential dangers incidental to engaging in the activity for which this registration is submitted and voluntarily and knowingly assumes the risks of engaging in the activity. I am aware that participating in this activity can be hazardous, and I am aware of the dangers involved which may place the participant involved at risk for possible injury, illness, including communicable diseases, death, or property damage and I hereby agree to accept, on behalf of myself and my child, any and all such risks.



    In exchange for the benefits derived by my child's participation in the Youth Programs,
    I HEREBY AGREE TO INDEMNIFY, HOLD HARMLESS AND NOT SUE THE ORGANIZATIONS AND THEIR EMPLOYEES, REPRESENTATIVES, AGENTS, SERVANTS, OR VOLUNTEERS for any liability, claims, or actions for injury, death, or damage to personal property arising out of or in connection with my child's participation in  ORGANIZATIONS’ youth programs from whatever cause including the active or passive negligence of the ORGANIZATIONS , their officers, employees, agents, representatives or volunteers.



    As Mother/Father/Legal Guardian (circle one) of the child named above, in the event I cannot be contacted in a medical emergency involving my child, I authorize the ORGANIZATIONS to consent to all emergency medical care proceedings to be rendered by a duly licensed health care provider or physician including but not limited to ordering of x-rays, performing tests, administration of drugs or any other medical or surgical care to the child.  I also authorize the ORGANIZATIONS to release any medical records necessary for treatment or insurance purposes and to provide or arrange transportation services for my child necessary to provide the emergency treatment.  This care may be given under whatever conditions are necessary to preserve the health and safety of the child.



    By signing this agreement, you are agreeing to relieve the City of liability for personal injury, wrongful death or property damage except as may be caused by the active negligence of the CITY. 



    Please Note: The City of Anaheim and its venues continue to do their part to stem the spread of coronavirus. Due to the safety guidelines currently in effect, please be aware that all of the following program information and scheduling is subject to change without notice.



    Face coverings:  Under the Governor’s reopening guidance, participants must wear face coverings in common and public indoor spaces and outdoors when distancing is not possible. Please bring and expect to wear a face mask or covering for the safety of you and others



    I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS.  I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND SIGN IT OF MY OWN FREE WILL.
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