Emergency Contact Form & Waiver of Liability



EMERGENCY CONTACT FORM & WAIVER OF LIABILITY

Child #1 Name                   D.O.B.:             Gender:              
School: Grade:    
           
Child #2 Name: D.O.B.: Gender:
School: Grade:    
           
Address: City: Zip:
Parent/Guardian:   Phone: Email:         
Parent/Guardian: Phone: Email:


In an emergency, when parent/guardian cannot be reached, please contact:

Name:  
Phone:  
Relation:  

Additional adult to whom child/children may be released:

Name:  
Phone:  
Relation:  

Medical conditions or allergies that we should know about:


Additional information about your child that might be helpful for us to know:

Important Notices and Disclosures

Cuts & Burns: The Activity Center encourages all young people to develop proficient and independent cooking skills. I understand that many classes, parties and camp activities involve the use of sharp knives and/or cooking equipment that may become hot or cause injury. While children are supervised, I understand there is always risk of minor cuts or burns.

Transportation: I understand day camp and some other programs include off site activities and field trips to local parks, pools, beaches, etc. The destinations will always be disclosed ahead of time. Transportation to and from destinations will be provided in Activity Center branded shuttle van or Santa Monica Big Blue Bus unless otherwise arranged in advance. In cases where transportation is provided in personal or corporate vehicles, all children under the age of 8 are required to ride in an appropriate booster seat. During off-site activities The Activity Center is locked and closed for business. No staff or children are permitted to remain behind.

Photo Release: I understand that children participating in day camp and some other programs may be photographed. I grant permission for The Activity Center to incorporate photographs of my child within its public website and social media accounts. It is agreed and understood that this permission extends only to photographs taken at The Activity Center or while attending camp and only for the purpose of promoting awareness of programs offered. Permission may be revoked at any time.

Waiver of Liability, Release, Assumption of Risk & Indemnity Agreement Notice:

This is a legally binding agreement. I understand that by signing this Waiver of Liability, I release and hold harmless The Activity Center, 3200 Activities, Inc., its owners, directors, officers, advisors, employees, agents, instructors, volunteers and all other persons or entities acting on their behalf from any and all claims, demands, suits, cost and charges, in connection with or arising out of services provided, including but not limited to: personal injury, bodily harm, injury, property damage and exposure to disease or infection.

I acknowledge the presence of COVID-19 in our community and recognize that even with the best safeguards there is no guarantee that I or my child may not be exposed to a carrier. I am voluntarily leaving my child and assume all health and safety risks associated with his/her participation in the program.

I authorize The Activity Center to seek appropriate medical treatment for my child in the event I cannot be reached.

I agree to pay all fees associated with instruction or care provided. I understand that if my child should become disruptive or inconsolable while on premises or during class or camp sessions, child may be asked to leave and no refund will be issued.

This one waiver shall cover participation in all classes, activities, camps and programs at The Activity Center for up to one year.

Agreed and accepted:

Leave this empty:

Signature arrow sign here

Signed by The Activity Center
Signed On: May 6, 2023


Signature Certificate
Document name: Emergency Contact Form & Waiver of Liability
lock iconUnique Document ID: ea218f8c645497210ecac76326165336a6686102
Timestamp Audit
June 11, 2022 1:38 pm PDTEmergency Contact Form & Waiver of Liability Uploaded by The Activity Center - sean@activitycentersm.com IP 172.91.111.250
Audit trial Qr code
This audit trail report provides a detailed record of the online activity and events recorded for this document.
https://activitycentersm.com/
Audit Trail Serial# fa205367adf3ad078cd30f1fb7535495