CHILD WAIVER
RELEASE, DISCHARGE OF LIABILITY AND ASSUMPTION OF RISK
Name of Participant (minor child):_____________________________________________________________
Participant’s Date of Birth:_____________________________________________________________________
Parent or Legal Guardian:_____________________________________________________________________
Address:_____________________________________________________________________________________
Telephone: ___________________________________Emergency Telephone:_________________________
Name of Class or Activity (“the activity”): Healthy Diamond Bar / Connect with Rec
I the undersigned, certify that I am the parent or legal guardian of the above-named child. I
enroll my child in the activity of my own volition and give him/her permission to participate.
My child is physically fit to participate in the activity and has not been diagnosed with any illness
or medical condition that would impair his/her ability to participate in the activity. No physician
has recommended against my child’s participation.
I am aware that the activity poses a risk of injury to my child, and that occasionally accidents
occur during activities of this kind. Knowing these risks, on behalf of myself and my child, I freely
and voluntarily agree to assume all of the risks associated with participation in the activity.
In consideration of my child being permitted to enroll and participate in the activity, I agree (on
my and my child’s behalf, and on behalf of my and my child’s successors, representatives,
executors, heirs and assigns) to release and discharge the Program Sponsors from any liability,
causes of action, claims or damages for personal injury, property damage and wrongful death
arising from or attributable to my child’s participation in the activity, whether or not such liability
arises from the program sponsors’ negligence in organizing, planning and implementing the
activity.
I understand that by signing this instrument, my child and I (and our legal representatives, heirs,
assigns or any other successors in interest) are barred from presenting any claim or instituting any
civil action or present any claim for personal injury, property damage or wrongful death against
the Program Sponsors who, through negligence or otherwise, might otherwise be liable to me, my
minor child, my minor child’s heirs, or other successors in interest for damages.
I HAVE READ THIS RELEASE CAREFULLY AND FULLY UNDERSTAND IT. I UNDERSTAND THE RISKS
INVOLVED IN THE ACTIVITY. I UNDERSTAND THAT BY SIGNING THIS RELEASE, I GIVE UP THE RIGHT TO
SUE THE PROGRAM SPONSORS. I SIGN THIS RELEASE FREELY AND VOLUNTARILY WITHOUT
INDUCEMENT.
In the event of a medical emergency, I authorize medical personnel attending to my child
to make decisions regarding immediate medical treatment as may be necessary until such
time as I can be consulted.
By registering for any recreation class or activity, I grant the City of Diamond Bar permission
to use my and/or my child’s photograph, video or film likeness, for promotional use in any
City-related media.
Participant’s Parent/ Participant’s Signature
Guardian Si
nature:
If 14
ears or older:
Name of Class/Activity: Healthy Diamond Bar/Connect w/Rec Date:
