2897 Kilgore Road
Rancho Cordova, CA 95670
(916) 875-9627
www.rcpdpal.org
FIELD TRIP / ACTIVITY CONSENT FORM

Event:
Kick off To Summer
End Of School Celebration
Date/Time:
June 24th, 2021  |  4:30pm - 6:30pm
Location:
Le Five Indoor Soccer 11115 Folsom Blvd., Suite 200 Rancho Cordova, CA 95670

Please complete the entire form. Children's Information:

Sex:
Child lives with:

Father/Mother/Guardian (Please list the BEST way to reach you)

Emergency Contact (Other Than Parents or Guardians)

Photo Release

I grant to Rancho Cordova Police Activities League, its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize the Rancho Cordova PAL, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that the Rancho Cordova PAL may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

and

AGREEMENT OF INDEMNITY RELEASE OF LIABILITY
AND ACKNOWLEDGEMENT OF RISK OF ACTIVITIES

I acknowledge and realize and am aware that my child will be participating in a variety of activities. I understand that there are elements of risks in any activity associated with participation. These risks include, but are not limited to, falling, tripping, being hit by another child, getting injured in a vehicle which is providing transportation, etc. I also acknowledge and understand that although Rancho Cordova PAL staff and volunteers may be present; those persons are not always able to prevent the possible injuries from risks that have been described above.

Therefore, I agree as follows:
1. Release
As a condition of and in consideration for being permitted by Rancho Cordova PAL to participate in the activities provided, I for myself and/or minor children for which I am a parent/legal guardian or otherwise responsible, any heirs, personal representatives, or assigns do hereby release, discharge, and covenant not to sue the Rancho Cordova PAL, its employees, principles, directors, officers, agents, volunteers, or anyone affiliated with the Rancho Cordova PAL and each/every landowner, municipal and/or governmental agency upon whose property an activity is conducted from all liability and waive any claim for damages arising from any cause whatsoever, except that which is the result of gross negligence.

2. Express Assumption of Risk and Responsibility
In recognition of the inherent risk of the activity which I and any minor children for which I am responsible, will engage in, I confirm that my child is physically and mentally capable of participating in this activity and using the equipment. My child is participating willingly and voluntarily. I assume full responsibility for personal injury, accidents and/or illness, including, but not limited to, sprains, torn muscles, bites, wounds, scrapes, abrasions and/or contusions; head, neck and/or spinal injuries, bites or attacks by animals or insects, allergic reactions, shock, paralysis, coma or death, and any related expenses that are related to my child. I assume all responsibility for damage to or loss of my/our personal property as a result of any accident that may occur.

3. Hold Harmless/Assumption of Risk
I agree that I/we will indemnify and hold harmless the Rancho Cordova PAL, the City of Rancho Cordova and the County of Sacramento, and any affiliated organization, its representatives, its employees, principles, directors, officers, agents, volunteers, or anyone affiliated with the City of Rancho Cordova and the County of Sacramento and each and every landowner, municipal and/or governmental agency upon whose property and activity is conducted, from any loss, all liability and waive any claim for damages or costs arising for any cause whatsoever related to my child’s participation, except that which is the result of gross negligence.
I further expressly agree that this assumption of risk, release and indemnity agreement is intended to as broad and inclusive as is permitted by the laws of the State of California and if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I also agree to take any, all and full responsibility for any interactions that occur relating to an employee of the City/County who is in any fashion associated with or having contact with my child outside the specific hours of the program.

4. Medical / Insurance Information

Do you have INSURANCE?:

5. MEDICAL RELEASE: AUTHORIZATION CONSENTING TO TREATMENT OF MINOR

I/We, the undersigned, parent(s) or legal guardians of

a minor, do hereby authorize the staff of the Rancho Cordova Police Activities League, or an authorized representative, as agent(s) for the undersigned, to consent to any X-Ray examination, anesthetic, medical or surgical diagnosis, treatment and hospital care which is rendered under the general or specific supervision of any physician and surgeon licensed under the provisions of the California Medicine Practice Act on the medical staff of a licensed hospital, whether such examination, diagnosis, or treatment is rendered at the office of said physician or at such hospital.
It is understood that this authorization is given in advance of any specific examination, diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of our above named agent(s) to give specific consent to any and all such examinations, diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may seem advisable.

I HAVE READ THE FOREGOING (Items 1 - 5) ACKNOWLEDGEMENT OF RISK, ASSUMPTION OF RISK AND RESPONSIBILITY, RELEASE OF LIABILITY, HOLD HARMLESS AGREEMENT, AND MEDICAL INFORMATION AND RELEASE. I UNDERSTAND THAT BY SIGNING THIS DOCUMENT, I AM WAIVING VALUALBE LEGAL RIGHTS. I DO SO VOLUNTARILY. I DO SO WITH FULL UNDERSTANDING THAT THE RANCO CORDOVA PAL, THE CITY OF RANCHO CORDOVA AND THE COUNTY OF SACRAMENTO ARE NOT TO BE HELD RESPONSIBLE, WHATSOEVER, OR AT ALL FOR INJURIES THAT MAY OCCUR TO ME AND/OR ANY CHILD OF MINE EXCEPT THAT WHICH IS CONCLUSIVELY DETERMINED TO BE THE RESULT OF GROSS NEGLIGENCE.
BY SIGNING AND VALIDATING THIS AS A PARENT OR GUARDIAN, I HEREBY AGREE THAT I AM DULY AUTHORIZED TO DO SO ON BEHALF OF MYSELF AND ON BEHALF OF ANY OTHER PARENT OR GUARDIAN TO THE PARTICIPATING CHILD.