8/3/2019 Bike Giveaway Registration Packet

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Youth and Community Outreach DepartmentRelease of Liability Form: Adults and Minors

Parent/Guardian Name(s) (print)______________________________________________________________________  

Parents Date(s) of Birth (same order)__________________________________________________________________ 

Address ________________________________ City _________________ Zip____________Military Housing? Yes/NoEmail Address ________________________________________ Service Branch _____________________ Rank_____  _ 

Home Phone __________________________ Work __________________________ Cell __________________________ 

Emergency Contact ________________________________________________________________________________ 

EC Home Phone _______________________ EC Work _______________________ EC Cell _______________________ 

Minor Children Participating:

Name _____________________________________________________ Date of Birth ________________ Gender ______  

Name _____________________________________________________ Date of Birth ________________ Gender ______  

Activity or Group ASYMCA & Ernst & Young LLP Bike Giveaway  Date(s) December 9, 2011 

Location  ASYMCA HQ 3293 Santo Road, San Diego CA 92124 (Santo Baseball Field) 

I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for theminor to participate in the San Diego Armed Services YMCA program described above. I hereby grant fullpermission for my child and/or myself to be photographed by the San Diego Armed Services YMCA staff for anylegitimate purpose without payment or compensation.  The minor is physically able and mentally prepared toparticipate in all activities as described in the announcement for the program. I hereby voluntarily and knowinglyassume all risks and dangers inherent and incidental to the activities of the program. I will not hold the San DiegoArmed Service YMCA liable for any injuries incurred during the program or while my child(ren) is/are in transit to andfrom the program whether caused by equipment or the act or omissions of others excepting damage or injury solelycaused by the willful misconduct or negligence of the San Diego Armed Services YMCA, or its employees,volunteers, or agents. 

I do hereby authorize the San Diego Armed Services YMCA as agent for the undersigned, to consent with respect tothe minors, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospitalcare which is deemed advisable by, and is to be rendered under general or special supervision of, any physicianand surgeon licensed under the provisions of the California Medical Practice Act on the medical staff of any hospital,whether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand thatthe San Diego Armed Services YMCA is not responsible for costs incurred for medical care. If I participate in theprogram, whether as coach, instructor, aide, spectator, or participant, I presently waive as to the San Diego ArmedServices YMCA and staff, officers and directors thereof, any claim presently known or unknown for damage toproperty or personal injury whether caused by equipment or the acts or omissions of others including San DiegoArmed Services YMCA personnel.

****Parent/Guardian (Signature)____________________________________ Date ___________________**** 

8/3/2019 Bike Giveaway Registration Packet

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Release

Use of Child’s Name and Likeness 

I, ________________________________________________, am the legal parent or guardian of the minor

child named below and I have the legal authority to execute this release on behalf of the child. I do hereby

give Ernst & Young LLP (“Ernst & Young”) the irrevocable right to use the child’s name, biographical

information, picture, portrait, or photograph (“Likenesses”) in all forms and in all media without restriction

as to changes or alterations (including but not restricted to composite or derivative works made in any

medium) for promotion, exhibition or any other lawful purpose in connection with the Ernst & Young-

Armed Forces YMCA children’s bike building event day in San Diego  (the “Event”), and I waive any right

to inspect or approve the photograph(s) or finished version(s) incorporating the photograph(s), including

written copy that may be created and appear in connection therewith.

I hereby release and agree to hold harmless Ernst & Young and the photographer,__________________________, and their respective assigns, licensees, successors in interest, legal

representatives and heirs from any liability arising out of use of the Likenesses, including but not limited to

claims for either invasion of privacy or libel. I agree that Ernst & Young owns the copyright in these

photographs and that Ernst & Young owns the usage rights to these photographs or works derived

therefrom.

Disclaimer of Warranties

I understand that the bicycle provided to my child in connection with the Event is provided “AS IS” AND

THAT NEITHER ERNST & YOUNG NOR ANY OTHER PARTY INVOLVED IN THE

CREATION, PRODUCTION OR DELIVERY OF THE BICYCLE MAKES, AND EACH

EXPRESSLY DISCLAIMS, ANY WARRANTIES, EXPRESS OR IMPLIED, WITH RESPECT

THERETO, INCLUDING, WITHOUT LIMITATION, ANY IMPLIED WARRANTY OF

MERCHANTABILITY OR FITNESS FOR ANY PARTICULAR PURPOSE OR USE. I hereby

release and agree to hold harmless Ernst & Young and its personnel, partners and vendors and their

respective assigns, successors in interest, legal representatives and heirs from any liability arising out of the

use or possession of the bicycle.

I am of full age and competent to sign this release. I agree that this release shall be binding on me, my legal

representatives, heirs, and assigns. I have read this release and am fully familiar with its contents.

Name of Minor Child _____________________________

Signed_________________________________________

Address________________________________________

_____________________________________

Date__________________________________________