Registration


PARTICIPANT NAME: _____________________________________________________________________________________________________________________________________________ ACTIVITY: _______________________________________________________________________________DATE OF BIRTH: _____________________________________ GENDER: __________


Medical Emergency Release: Authorization and Consent of Parent(s) or Legal Guardian(s)


Pursuant to California Family Code §6910, I am a parent or legal guardian having legal custody of the minor child identified above, and do hereby authorize the City of Carlsbad, its officers, employees, agents, representatives, and assignees, whose care such minor child has been entrusted, to consent to any examination, X-ray examination (or similar examination such as by CAT scan), anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the California Medical Practice Act or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the California Dental Practice Act. I agree to pay any and all costs for the foregoing care. In consideration of my child’s participation in the sponsored activity, I hereby release, hold harmless, and discharge the City of Carlsbad, its elected official, officers, employees, agents, representatives, and assignees from any and all claims for personal injuries and damages.


This authorization is effective on the ___________________ day of _______________________,20______________ , and shall be valid for one year. Signed this _______________ day of ________________________________________________ ,20 _____________ .


SIGN HERE >> PARENT/GUARDIAN #1’S SIGNATURE _______________________________________________________________________________________________________ PARENT/GUARDIAN #2’S SIGNATURE ________________________________________________________________________________________________________


Insurance Co. _______________________________________________________Policy #______________________________________________ Dentist Name _______________________________________________________Phone: ______________________________________________ Dentist Address __________________________________________________________________________________________________________ Insurance Co. _______________________________________________________Policy # _____________________________________________ Family Physician ____________________________________________________Phone _______________________________________________ Address _________________________________________________________________________________________________________________ Pertinent medical history information (Epilepsy, diabetes, allergies, etc.)___Yes ___No. If yes, explain: _________________________________________________________________________________________________________________________ Parent/Legal Guardian Emergency Phone # _________________________________________________________________________________ In case of emergency (if Parent/Legal Guardian cannot be contacted) please notify: Name ________________________________________Relationship to child: ______________________Phone ___________________________ Name ________________________________________Relationship to child: ______________________Phone ___________________________ My child takes the following medications on a regular basis: _____________________________________________________________ Staff is not permitted to dispense any medication not prescribed by a physician. A physician’s note must accompany the medication that is to be dispensed.


Name of Child ___________________________________________________________________________________________________________ Medicine ___________________________________________________ Time Given ________________ Dosage _______________________


Photographic Release


I permit the Parks and Recreation Department to use and publish photographs and/or videotapes of me and/or my children for purposes of presenting recreation activities to the community and to promote the recreation program to prospective clients and/or participants. I also give permission to release such photographs and/or videotapes to the news media in support of the program.


____________________ (Please Initial) << INITIAL HERE Code of Conduct Release


The City of Carlsbad Parks and Recreation Department encourages a safe and healthy atmosphere by supporting an environment free from: Drugs or Alcohol, Violence, Intimidation, or Harassment, Gambling or Solicitation, Profanity, or Abusive Language, Vandalism or Property Damage. This code of conduct applies to all participants, spectators, visitors, facility users, organizations or groups, staff and volunteers in any and all Carlsbad Parks & Recreation Department Activities, Programs, Field and Facility Uses.


Violation of this Code of Conduct may result in disciplinary action up to and including immediate and permanent expulsion from Carlsbad Parks & Recreation Programs, cancellation of any facilities or field reservations, forfeiture of any and all fees, and financial or other restitution for any damage. Acts conducted by a minor are the responsibility of the parent or guardian. I have read and agree to abide by the City of Carlsbad's Code of Conduct and accept responsibility for any acts on behalf of my child in violation of this code.


____________(Please Initial) << INITIAL HERE HAVE YOU SIGNED IN THREE PLACES AND INITIALED IN TWO PLACES? YOUR FORM IS NOT COMPLETE UNTIL YOU DO. 48


Winter-Spring 2011-2012


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