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Forms
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Bear River Recreation and Parks District
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Print, Fill Out and Mail to: BRRPD After-School Childcare Program
10042 Wolf Rd., Suite B, #11 Grass Valley, CA 95949
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Drop in office Mail Slot at: 10516 Combie Rd., Auburn, CA 95602
In the Combie Plaza near Paws and Claws
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After-School Childcare Program - 2008/09
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Registration, Waiver and Release Form Updated Aug. 13, 2008
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| Name: ___________________________ |
Grade: __________ Girl Boy (Circle One) |
| Address: _________________________ |
e-mail: _______________________________ |
| City: ____________________________ |
Phone: _______________________________ |
| State:________________ Zip: ________ |
Emergency Phone: ____________________ |
| Cash: _______ Check#: ____________ |
Total Amount Enclosed: $_______________ |
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| Payments |
□ Monthly - $15/day X No. of |
Scheduled Days per Month |
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□ $180.00 - 10 day Punch Pass |
□ $35.00 - Full Day |
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□ $360.00 - 20 day Punch Pass |
□ $40.00 - Drop-in Full Day |
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□ $5.00 Additnl - Minimum Day |
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In consideration for being permitted by the Bear River Recreation and Parks District (BRRPD) to participate in the above activity, I hereby waive, release, and discharge any and all claims for damages for personal injury, death or property damage which may have, or which may hereafter accrue to me, as a result of participation in said activity. This release is intended to discharge in advance the BRRPD (its officers, employees, volunteers, and agents) from any participation in said activity, even though that liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above. It is understood that this activity involves an element of risk and danger of accidents and knowing those risks I hereby assume those risks. It is further agreed that this waiver, release and assumption of those risks is to be binding on my heirs and assigns. I agree to indemnify and to hold the above person or entities free and harmless from any loss, liability, damage, cost or expense which they may incur as the result of my death or any injury or property damage that I may sustain while participating in said activity.
PARENTAL CONSENT: (TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN IF APPLICANT IS UNDER 18 YEARS OF AGE). I hereby consent that my son/daughter ______________________, participate in the above activity. I hereby execute the above Agreement, Waiver, and Release on his/her behalf. I state that said minor is physically able to participate in said activity. I hereby agree to indemnify and hold the persons and entities mentioned above free and harmless from any loss, liability, damage, cost, or expense which they may incur as a result of the death or any injury or property damage that said minor may sustain while participating in said activity.
I HAVE CAREFULLY READ THIS AGREEMENT, WAIVER, AND RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I am aware that this is a RELEASE OF LIABILITY and a CONTRACT between myself and BRRPD and I SIGN IT OF MY OWN FREE WILL.
Signature_____________________________________Date______________________
(Parent or guardian required if student / player is under 18 years old)
Name Printed _____________________________________________________________
Address _____________________________________________________________
Home Number ________________________ Work Number ________________________
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