DEPARTMENT OF PARKS & RECREATION
STATEMENT OF NON-CONVICTION FOR POTENTIAL
EMPLOYEES, CONTRACT INSTRUCTORS OR VOLUNTEERS
AB 1663 created the law that makes cities, operating parks, playgrounds, and recreational centers liable under civil law if employees or
volunteers with supervisory or disciplinary authority over any minor have been convicted of any child molestation crime, sex crime, drug
crime, or any crime of violence.
Therefore, under penalty of perjury, I state that I
Print Name: Last Middle First
Sex Birth Date Birth Place Height Weight
Social Security Number CA Driver’s License Number
have not been arrested and pending trial nor have I been convicted of any criminal activity involving child molestation crime, sex crime,
drug crime, or any crime of
violence.
I also give permission to the Huntington Park Police Department to use the California Law Enforcement Telecommunication System
(CLETS) and my fingerprints to
check my status as to any criminal
activity.
I give permission for the minor in my custody to participate in the above mentioned program/activities and hereby waive, release and
discharge any and all claims of the right to claim for damages for death, personal injury or property damage which may have, or which
may hereafter occur to me, as a result of said minor’s participation in said activity. This release is intended to discharge in advance the
City of Huntington Park, its officers, employees, agents, game officials, managers and coaches from and against any and all liability
arising out of or connected in anyway with said minor’s participation in said activity, even though that liability may arise out of negligence
of carelessness on the part of the persons or entities mentioned above. I further understand that serious accidents occasionally occur
during said activity, and that participants of such activity occasionally sustain mortal or serious personal injuries, and/or property
damage, as consequence thereof: Knowing the risks of said activity, nevertheless, on behalf of said minor child, I hereby agree to
assume those risks and to release and hold harmless all of the person’s entities mentioned above who, through negligence and
carelessness, might otherwise be liable to me, or my heirs of assigns for damages. I further permit the use of activity/event photography
and/or videotaping for promotional use of the City of Huntington Park’s Web site, brochures and public television. It is further understood
and agreed that this wavier, release and assumption of risk are to be binding on my heirs and assigns. I agree to accept and abide by
the rules and policies of the City of Huntington Park, Department of Parks & Recreation. This authorization shall remain in effect for all
activities related to the above unless otherwise individuated or revoked in writing and delivered to said gent. The undersigned agrees
that this Agreement, Release and Indemnity is intended to be as broad and inclusive as permitted by the laws of the State of California,
and that if any portion of this document is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and
effect.
I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS
CONTENTS. I AM AWARE THAT IT IS A FULL RELEASE OF ALL LIABILITY
AND I SIGN IT BY MY OWN FREE WILL.
Huntington Park, CA 90255
