Teen Center Membership Application

Participant Information*

First NameLast Name

Date of Birth*

Date

Grade*

Participant's Email*

example@example.com

School*

Preferred Pronouns (to be used by staff)

Pick One

MaleFemaleNon-Binary

Parent / Guardian Information*

First NameLast Name

Relationship*

Phone Number*

Please enter a valid phone number.

Address*

Email*

example@example.com

Parent / Guardian Information (2)

First NameLast Name

Relationship

Phone Number

Address

Email

example@example.com

EMERGENCY INFORMATION

Name

Relationship

Phone

EMERGENCY INFORMATION (2)

Relationship

Phone

MEDICAL INFORMATION

Medical Coverage

Medical Identification #

Allergies?*

YesNo

If answered yes, please list them below

List Dietary Restrictions

List Current Medications

Photo / Video Release Statement

I hereby give permission to the City of Palo Alto, Community Services Department to use my (or additionally listed) name and photograph in all forms and media for advertising, trade, and any other lawful purposes.*

YES, I permit my child/children to be photographed and/or videotaped while in a City of Palo Alto programNO, I do not permit my child/children to be photographed and/or videotaped while in a City of Palo Alto program

PROGRAM AGREEMENT*

I agree that have read, understand and will abide by the policies, standards, rules and community agreements ofthe Mitchell Park Teen Center as stated in the Handbook. - understand that failure to comply with these rules will result in disciplinary action, which can include sitting out of activities, suspension from a program / day / event, suspension for a period of time from the Teen Center or being suspended indefinitely.

WAIVER:

All classes require the signature of each registering adult or parent or guardian of any minor(I give permission to participate in the following programs, including any associated travel sponsored by the City of Palo Alto Community Services Department for myself and/or child as named in consideration for participation in the programs, agree to the following: l understand that participating in the program is a voluntary activity that am choosing to participate in and is not required. l understand that there are inherent risks in participating in the programs which may be both foreseen and unforeseen and include illness, physical injury and death.

l understand that there is a Coronavirus pandemic in effect, that the City will provide the programs in compliance with the guidelines of the Santa Clara County Health Order in effect and any superseding orders of the State of California with regard to the Coronavirus, and that despite the City's compliance with such guidelines, the City cannot guarantee that there is no risk of transmission of the Coronavirus. I understand that participants will be required to use safety gear consistent with such health orders, including, without limitation, face coverings and hand sanitizer, and will be required to follow social distancing guidelines and other safety protocols. also agree that participants must be symptom free (no coughing or fever) in order to participate in the program, and will not have been knowingly exposed to Coronavirus within the 2 weeks prior to participationin the program. Additionally, agree to ASSUME ALL RISKS of participating in the programs. agree to DISCHARGE AND RELEASE (agreeing to make no claim and not to sue) and HOLD HARMLESS the City of Palo Alto, its employees, its agents, its independent contractors, and volunteers working for the City, from any and all liability for injury suffered by me or my child arising from or connected with these programs. lunderstand and agree that this ASSUMPTION OF THE RISK, DISCHARGE AND RELEASE, AND HOLD HARMLESS includes any claims relating to the actions, omissions, or negligence of the City, its employees, agents, independent contractors, and volunteers.

If participant's family member or someone in close contact with the participant (outside of this program) tests positive for COVID-19, or if participant tests positive for COVID-19, lige permission for the City to notify other people in contact with the participant (including other program participants, staff, and volunteers) that they may have been exposed to COVID-19. In doing so, the City shall not identify the participant or their family by name except as required by government mandates l additionally understand and agree that in compliance with Appendix C-1 of the Santa Clara County Public Health Order (effective July 13, 2020).

I acknowledge that have carefully read this liability waiver and understand the information herein, and that I agree to each of the terms and acknowledgments in this liability waiver.

Parent/Guardian's Name*

Date*

Date

Signature*

Participant's Name*

Date*

Date

Signature*

Participant's Photo (Please upload the participant's photo behind a solid colored wall. This will be used for the membership card.)*

You will receive a confirmation from staff via email when your membership application has been processed. You will also received details of how you can complete payment and when you can pick up your child's MEMBERSHIP ID

MITCHELL PARK TEEN CENTER

MEMBERSHIP FORM