Back 2 School Bowling

Back 2 School Bowling Registration Aug 14th at Delta Bowl

Please note: This event is only for Antioch residents or AUSD students.
It's that time again, we invite all youth ages 12-18 to our Back to School Bowling on August 14th from 5:30pm-7:00pm. You can enjoy free bowling, and food surrounded by old, and new friends. We hope to see you then.

Please note: A parent/guardian's signature is required to sign their child out at the end of the event. Every youth must stay for the whole event, if you need to leave early you will need to have a parent/guardian sign you out, or have verbal confirmation. Please come to the front entrance to sign out your youth. Please contact youth@antiochca.gov if you have any questions or concerns.
Youth Name:

First NameLast Name
Youth Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Youth E-mail:
example@example.com
Birth Date:

MonthDayYear
Date
Age:
What school do you attend?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts:

*Please fill out who we could contact incase of an emergency.
1. Parent/Guardian name:

First NameLast Name
Parent/Guardian Phone Number:
Format: (000) 000-0000.
Parent/Guardian E-mail:
example@example.com
2. Parent/Guardian name:

First NameLast Name
Parent/Guardian Phone Number:
Format: (000) 000-0000.
Parent/Guardian E-mail:
example@example.com
Allergy Information:

*Please include any allergy or dietary restrictions.
Do you have any allergies or dietary restrictions? If so, please list them down below and include what steps to take when encountering an allergic reaction:
Designated Pick-up Information:

*Please note: Youth will be released to parent/guardians, or designated pick-up adults only.
1. Designated pick-up(must be different than parent/guardian):

First NameLast Name
Designated Pick-up Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
2. Designated pick-up Name:

First NameLast Name
Designated Pick-up Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Medical Authorization
I authorize any City of Antioch employee to perform emergency procedures, including assisting with the administration of epi-pens, injections or self- administered medications (whether over the counter or prescription) or any other steps that I have described above to treat any illness, medical condition, allergic reaction, or injuy that my child may experience. I recognize and acknowledge that there are certain risks of injury in connection with administration of medication to any minor child. Such risks include, but are not limited to, failing to properly administer the medication, failing to observe side effects, failing to assess and recognize the adverse reaction, failing to assess and/or recognize a medical emergency, and failing to recognize the need to summon emergency medical services.

I hereby authorize City of Antioch employees or staff to assist in the administration of medication on my behalf or allow my child to self-administer (if permitted by my child's physician)the lawfully prescribed Epi-Pen or other medication in the event of an allergic reaction by my child. I acknowledge the assistance in administration of the Epi-Pen or other medication to my child by an individual who is not a nurse or medical professional may be necessary, and I specifically consent to such practice.

I hereby waive any claim for myself, my heirs, executors, assigns or personal representatives that I may have against the city of Antioch, its officals, officers, employees, agents or volunteers, from any and all claims for damages arising out of or in any way connected to the self-administration, assist-in administration, failure to administer or attempt to administr any medcation to my child.I further agree to protect, indemnify, defend and hold harmless the City of Antioch, its officials, officers, employees, agents, and volunteers, for any claims for damages, including attorney fees, arising out of or in any way connected to the self-administration, assist-in-administration, failure to administer or attempt to administer medication to my child. I also give my permission to the City of Antioch staff to contact emergency services or obtain emergency medical treatment if necessary. I agree to be wholly responsible to payment if any and all medical and emegcency services rendered to my child.
Media Release Waiver
By checking this box I hereby authorize the City of Antioch, its affiliates, and their respective employees, agents, volunteers, and/or contractors (“City”) to photograph or otherwise record my likeness or that of the below-named individual under 18 years of age. I further grant the City the irrevocable, perpetual and unrestricted right and permission to, use, re-use, publish, and republish my likeness in photographs, pictures, videos or other medium in any and all of its publications, including, without limitation, web-based publications and social media and such other medium as the City may desire. I understand and agree that all photos, videos, or other medium featuring my likeness will become City property, and will not be returned. I hereby irrevocably authorize the City to edit, alter, copy, exhibit, publish, or distribute these photos, videos, or other medium for any lawful purpose. I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photos, videos, or other medium. I further irrevocably authorize the use of my likeness in conjunction with my own or a fictitious name, and in any and all media now or hereafter known for illustration, promotion, art, editorial, advertising, trade, public-service advertisements to promote the City, or any other lawful purpose. I hereby release, discharge, and agree to hold harmless the City from any liability related to this release, including, without limitation, any claims for defamation or violation of any right of publicity or privacy. This release constitutes a waiver of any and all rights under California Civil Code section 3344, and any related statutes. I hereby warrant that I am at least 18 years of age and have the right to contract in my own name, or, if I am under 18 years of age, I have obtained the required consent of my Parents/Guardians as evidenced by their signatures below. I have read the above authorization, release, and agreement, prior to its execution, and I am fully familiar with the contents of this document. This document shall be binding upon me and my heirs, legal representatives, and assigns.
Parent/Guardian Signature
Walk Waiver:

(Waivers for Youth Participants who walk to and/or from program)
I, give my youth, permission to walk to and from the Antioch Community center, Antioch Senior Center, Nick Rodriguez Community Center, or Antioch City Hall, Youth event(location varies based on the event). I understand he/she will not be supervised on his/her walk to camp or home.

Waiver & Release: I, the undersigned, in consideration of participation in the activity listed above agree to indemnify and hold harmless the City of Antioch agents and its employees from any and all liability for any injury suffered by the above named participant arising out of or in any way connected with participation in the activity.
Please check here if you give permission for your youth to walk home.
Parent/guardian signature
Should be Empty:

Back 2 School Bowling Registration Aug 14th at Delta Bowl

It's that time again, we invite all youth ages 12-18 to our Back to School Bowling on August 14th from 5:30pm-7:00pm. You can enjoy free bowling, and food surrounded by old, and new friends. We hope to see you then.

Emergency Contacts:

Allergy Information:

Designated Pick-up Information:

Medical Authorization

Media Release Waiver

Walk Waiver: