CITY OF MOORPARK
MINOR VOLUNTEER*
INFORMED CONSENT AND RELEASE
Event or Activity:_________________________________________________________
Date (or Schedule):_______________________________________________________
Location:________________________________________________________________
INFORMED CONSE
NT AND RELEASE: I, the undersigned, hereby assume full responsibility for
all risk of injury or loss which may result from my participation or my child’s participation in this
volunteer activity and hereby AGREE TO DEFEND, INDEMNIFY, HOLD HARMLESS, RELEASE
AND FOREVER DISCHARGE the City of Moorpark, its respective officers, agents and employees,
past and present, from any and all acts of negligence and all claims and demands whatsoever,
which the undersigned, any third person, or any persons acting under their behalf, have or may
have against the City of Moorpark, or its respective officers, agents or employees, past and
present, by reason of any accident, communicable diseases, viruses, illnesses, injury to or death
of any person or persons, or damage to or loss or destruction of any property arising or resulting
directly or indirectly from participation in the referenced activity and occurring during said
participation, or any time subsequent thereto. The terms of this release will serve as a release
and assumption of risk for my heirs, executors, and administrators and for all of my family
members. I agree and acknowledge that some activities may include physical and/or strenuous
exercise or activity, and understanding this, I state that to the best of my knowledge the
participant has no medical, physical, mental, or emotional health condition which would hinder
or prevent active participation in the volunteer activity.
PLEASE NOTE: The City of Moorpark strongly recommends that each volunteer participant
have some type of accident medical insurance for his/her own protection. The City of
Moorpark does not provide medical insurance for volunteers. The City does provide Workers’
Compensation coverage for selective City volunteers, pursuant to the provisions of Section 3363.5
of the Labor Code, during the time the designated volunteer actually performs volunteer services
on behalf of the City of Moorpark. The currently designated selective City volunteers that are
provided with workers compensation coverage are Police volunteers, youth basketball coaches,
Senior Nutrition Program drivers, and disaster workers. No Workers’ Compensation coverage is
provided by the City of Moorpark for non-designated volunteers, including student
volunteers, such as those students participating in the Moorpark Unified School District’s
Community Service Learning Program, or the Ventura County Superintendent of Schools Office
vocational skill training programs.
Volunteer Name (PRINT): _________________________________________________________
Address: ______________________________________________________________________
Home Phone No.: _______________________
Cell Phone No.: ________________________
Parent’s Name (PRINT): __________________________________________________________
Parent/Guardian’s Signature*: __________________________________ Date: ____________
*A Parent or Legal Guardian signature is required for a minor volunteer under the age of 18.
799 Moorpark Avenue
Moorpark CA 93021
Revised 6.30.20
City: __________________________
Zip:____________________
Email Address: _________________________________________________________________
Date of Birth: __________________________
