A. Youth Waiver (Please fully complete waiver with a pen)
Parcipant Name:
Birthdate: Age: T-Shirt Size: Gender: Male Female
B. Compleon required by all parcipants. If Primary and Secondary do not reside at the same address, complete secon D.
Household Mailing Address: Zip Code:
Household Phone Number:
Household Primary Name: Birthdate:
Gender: Male Female Primary Email:
Primary Cell Phone
*
: Provider: Primary Work Phone:
Household Secondary Name: Birthdate:
Gender: Male Female Secondary Email:
Secondary Cell Phone
*
: Provider: Secondary Work Phone:
Program Registraon and Waiver Form
Ausn Parks and Recreaon Department
200 South Lamar
Ausn, Texas 78704
Phone: ( 512) 974-6700
E. Compleon required of all parcipants
Medical Care Informaon:
Any known allergies to food, drugs, insect sngs, poison ivy/other plants, etc.?
[Yes
] [No
] Please specify:
Please list any medical condion or limitaons that could restrict acvies or require
special care in order for youth to parcipate in the program or acvity.
Youth & Children Only: Does parcipant require prescripon medicaon during
program hours? Program must exceed 1 hour. [Yes
] [No
] If yes, please
complete a Medicaon Authorizaon Form.
Accessibility Modicaon Request
The City of Ausn is proud to comply with the Americans with Disabilies Act so that
ALL individuals can enjoy and benet from our recreaon and leisure services. If you
require assistance or a modicaon for parcipaon in our programs or for use of
our facilies, please call 512-974-3914 to consult with an Inclusion Coordinator at
least two weeks prior to an event, acvity or registraon deadline. Do you require a
modicaon? [Yes
] [No
] (Oponal)
Personal Informaon Privacy Policy
We collect personally idenable informaon like names, postal addresses, email, etc.
when voluntarily submied by our visitors. The informaon you provide is only used to
fulll your specic request, unless you give us permission to use it in another manner,
for example to add you to one of our mailing lists.
[email opt out?
]
Image Release Waiver
I hereby consent to allow usage of photographs and video taken during this program and
at our sites for publicity purposes in printed materials and on our website. Photographs
remain the property of the City of Ausn Parks and Recreaon Department. If you do
not want to allow photos or videos, then please inial.
[opt out?
]
Standards of Care Nocaon
Children’s programs/acvies supervised by the Parks and Recreaon Department and
requiring enrollment/registraon in order to parcipate are not licensed by the state,
but follow standards of care adopted in City of Ausn Ordinance No. 20190307-041.
Copies of the ordinance are available and posted at each site.
Release of Liability
In consideraon of parcipant being allowed to parcipate in the registered class(es)
or program(s), the undersigned hereby releases the City, its employees and agents,
from any acon, claim or demand for personal injury or property loss arising from or
due to any negligent act or omission of the City, its agents or employees. This release
shall have no eect with regard to damages caused by the City’s gross negligence. In
the event the City or a volunteer provides transportaon for the registered parcipant,
this waiver and release shall extend to and release the City employee driver from any
and all liability. Permission is given for any emergency medical treatment, operaon or
anesthesia which might become necessary. I agree to be responsible for the expense of
medical treatment or service.
Please Print Name:
Signature: Date:
Emergency Contact Name Relaonship Home Phone Work Phone Cell Phone Allowed to Pick-Up?
Yes No
Yes No
Yes No
Yes No
Yes No
C. Compleon required by all parcipants. List Emergency Contacts other than household members listed above.
D. Only complete this secon if a youth parcipant resides within two dierent households.B. Only complete this box if a Youth Parcipant resides within two separate Households.
Household Mailing Address: Zip Code:
Household Phone Number:
Household Primary Name: Birthdate:
Gender: Male Female Primary Email:
Primary Cell Phone
*
: Provider: Primary Work Phone:
Household Secondary Name: Birthdate:
Gender: Male Female Secondary Email:
Secondary Cell Phone
*
: Provider: Secondary Work Phone:
* By giving us cell phone numbers, you consent to being contacted at that number. We may contact you in person, by recorded
message, by the use of automated dialing equipment, by text (SMS) message for reasonable business purposes. Standard data
rates may apply, according to your wireless plan.
click to sign
signature
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