Won Academy Parent Consent form

Won Academy at Rancho san Joaquin GC. ("CLUB") Activity/Event Registration - Minor

Full Name of Minor/Participant

Date of Birth

Date

Address

Street Address Line 2

CityState

Zip

Parent(s)/Legal Guardian(s) (*Representative")

Home

Work

Emergency Contact

Relationship

Description of Activity/Event

Medical Information - Minor/Participant

Known allergies/sensitivities

Current medications and dosage amounts*

Current medical conditions

Additional information relevant to care, including medical history or special conditions/needs

Name of physician

Phone

Names of people to whom Participant may be released (must be at least 16 years old and ID will be required)

Phone

*if child needs medication during the Activity/Event, a completed Consent to Administer Medication form is required

ASSUMPTION OF RISK. RELEASE AND INDEMNIFICATION AGREEMENT

Assumption of Risk. Representative and Participant are aware that the Activity/Event involves inherent risks, dangers, and hazards that can resultin serious personal injury or death. Representative and Participant are also aware that the Club facilities and/or equipment contain dangers and can cause serious injury or death. Representative and Participant hereby freely agree to assume and accept all known and unknown risks of injury arising out of the Activity/Event, including injury or death that results from Club's negligence, design of the facility and/or equipment, or from any third party.

Release and Indemnity. In exchange for the Club allowing Participant to participate in the Activity. Representative, individually and on behalf of Participant as well as any respective family members, heirs beneficiaries, assigns and all parties claiming by, through or under either Representative or Participant, does hereby RELEASE, INDEMNIFY AND HOLD HARMLESS the Club, its parent, affiliated and subsidiary companies as well as all of their respective officers, directors, agents, contractors, employees, heirs, successors, assigns, volunteersand guests (the "Released Parties") from all liability for any injury, death, loss or damage connected in any way whatsoever to Participant's participation in the Activity/Event, WHETHER CAUSED BY NEGLIGENCE OF ANY OF THE RELEASED PARTIES OR OTHERWISE, including that which may result, directly or indirectly. in whole or in part, from the negligence or willful misconduct of the Released Parties or any third party, or from the design of the facility and/or equipment, whether on or off the Club's premises and including any transportation.

Medical Consent. Representative hereby gives consent to the Club to obtain all emergency medical care and transportation in order to obtain treatment in the event of injury. as the Club may deem appropriate, and Representative hereby accepts full responsibility for the payment of all costs for same. The release, indemnity and hold harmless provisions set forth hereinabove shall extend to any damage or loss arising out of the medical treatment and transportation provided in the event of an emergency, including the negligent acts or omissions of any health care providers, their agents, employees or representatives.

Property Loss, All personal property brought to the Activity is brought at the sole risk of the Participant as to its theft. damage or loss.

Photograph Release. Representative hereby grants permission to and releases the Club to use, without limitation or obligation, photographs, film footage or tape recordings that may include Participant's image or voice for purposes of promoting the Club's programs.

Severability, Any provision or portion of this Agreement found to be invalid by the courts having jurisdiction shall be invalid only with respect to such provision or portion. The remaining provisions or portion hereof, shall be construed and enforced to the same effect as if such offending provision or portion thereof had not been contained herein.

Representative hereby executes this Agreement on behalf of Representative and Participant.

Signature of Representative

Date