Palmdale Partners Academy Application 2026

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ATTENDANCE

The class is held on nine consecutive Wednesday evenings from August 19, 2026, through October 14, 2026, with a final class dinner on October 22, 2025. Are you able to attend at least 7 of the 9 sessions?

Age Group

Do you require a vegetarian option for the Graduation dinner?

Please list any food allergies

COMMUNITY ENGAGEMENT

Please list any community organizations, clubs or school programs in which you participate

Please briefly explain your interest in attending the Palmdale Partners Academy

PHOTO AND VIDEO RELEASE, CONSENT AND WAIVER

(California Civil Code Section 3344)

Check one of the following

I hereby consent and give the City of Palmdale the irrevocable right to use my photograph/image/likeness/video in all forms and manner and edit, use, reproduce, exhibit, and distribute this photograph and video in whole or in part, in any manner and media now known or from now on invented including, but not limited to, print, publications, the above-listed agencies' websites, YouTube, Facebook, and Instagram in perpetuity throughout the world, in support of and to promote the above-listed agency programs, services, and mission, and for archival purposes.

I waive the right to inspect or approve any photograph and/or video before use. I will not be compensated for the use of the photographs and/or videos. I expressly release and hold harmless the above-listed agencies and those acting under the above-listed agency's authority from liability for any claims by me or any third party for the actions of the above-listed agencies in reliance on this content and release.

I have read and fully understand the terms of this consent and release.

ELECTRONIC SIGNATURE AGREEMENT

By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the same sense as a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at al later date.

By checking "I agree," you acknowledge and accept the terms of the Electronic Signature Agreement.

Name

First NameLast Name

Signature

Date

FOR PERSONS UNDER 18 - APPROVAL OF PARENT/LEGAL GUARDIAN

I represent that I am the parent/legal guardian of the person who has signed the above release and I hereby authorize and consent to the use of photographs and videos as outlined in the foregoing content and release and otherwise agree to its terms.

ELECTRONIC SIGNATURE AGREEMENT

By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the same sense as a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at al later date.

By checking "I agree," you acknowledge and accept the terms of the Electronic Signature Agreement.

Name

First NameLast Name

Signature

Date

GENERAL PARTICIPANT RELEASE OF LIABILITY WAIVER

Participant Name

First NameLast Name

Parent/Guardian Name

First NameLast Name

Activity Name

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

Emergency Contact Name

First NameLast Name

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Relationship

Please list any medications the participant is taking

GENERAL RELEASE, WAIVER, AND ASSUMPTION OF RISK

I am fully aware of and understand the potential risk involved with my or my child's participation in this activity. Dangers could include, but aren't limited to cuts, broken bones and other debilitating or permanent physical and emotional injury, damage to personal property, or death. I understand that equipment, if any, which may be provided for the Participant's protection may be inadequate to prevent serious injury. I also understand that I may not be aware of potential risks.

Nevertheless, I acknowledge that I voluntarily elect to participate in this program or allow my child to participate (hereinafter either is "Participant"). I hereby agree to assume all risk of injury, damage to persons and property, or death and to hold the above-listed agencies, its elected and appointed officials, officers, employees, agents, and volunteers harmless from any liability for any injuries, or claim for damage, damage to goods, or death that may arise in connection with participation in this program. This release, Waiver, and Assumption of Risk ("Release") also pertain to any action of the above-listed agencies, its elected officials, officers, employees, agents, and volunteers (except only the sole negligence or willful misconduct of the above-listed agencies) which may have caused or contributed to the injury, damage, or death. This release shall be binding upon my heirs, executors, administrators, successors, assigns, dependents, and myself. I allow Participant to participate freely and voluntarily in this activity and expressly assume all the risks of this activity. In the event of illness, or medical emergency, I authorize and contest to all the above-listed agencies and their agents and employees to provide, administer, initiate, or obtain any necessary medical treatment for Participant. I hereby agree to assume all risk of injury, damage, or death and to release, forever discharge, and hold the above-listed agencies, its elected and appointed officials, officers, employees, agents, and volunteers harmless from any liability for any injuries, or claim for damage, or death that may arise as a result of medical treatment provided to Participant.

I hereby agree to indemnify, defend and hold harmless the above-listed agencies and their elected and appointed officials, officers, employees, agents, and volunteers from any loss, liability, damage, or cost they may incur due to any injury, damage, death or claims arising from Participant's presence in, upon or about the above-listed agencies premises or facilities or equipment or participation in the activity, whether by above-listed agencies negligence, Participant's negligence, another participant's negligence, or otherwise.

Participant expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of the State of California and that this Release shall be governed by and interpreted under the laws of the State of Claifornia. I agree that if any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected.

COVID-19 RELEASE, WAIVER, AND ASSUMPTION OF RISK

I acknowledge that the above-listed agencies are making recreation services available to me during the global COVID-19 outbreak. I understand that the above-listed agencies are taking reasonable measures to prevent the spread of COVID-19 infection, including tracking/tracing and following applicable State and Los Angeles County public health orders. However, an inherent risk of exposure to COVID-19 currently exists in any public place where people are present, and the possibility of transmission cannot be eliminated. COVID-19 is an extremely contagious disease that can lead to severe illness and death. According to the CDC, senior citizens and individuals with underlying medical conditions are especially vulnerable. By participating in the City's program, I voluntarily assume all risks and agree to hold the above-listed agencies harmless from any damage related to exposure to COVID-19. I know that Participant may be exposed to COVID-19, and I accept the risk and take full responsibility for such.

I agree to adhere to any current State and Los Angeles County COVID-19 orders. I acknowledge that Participant may be asked to leave the premises for failure to follow orders and forfeit fees paid for services. I represent that Participant has not had, nor has anyone in Participant's household, within the previous ten (10) days exhibited any COVID-19 symptoms as defined by the CDC. I agree that Participant will not attend recreation services offered by the above-listed agencies if any of the following conditions apply:

Participant or anyone in Participant's household has exhibited any COVID-19 symptoms in the last ten (10) days.
Participant or anyone in Participant's household has been diagnosed with COVID-19, has a suspected diagnosis of COVID-19, or is pending a COVID-19 test.
Participant or anyone in Participant's household has spent time with another individual who has been diagnosed with COVID-19 or has a suspected diagnosis of COVID-19.
Participant or anyone in Participant's household is currently under isolation or quarantine orders.

If Participant cannot continue participating in recreation services due to COVID-19, I may request a partial refund for services not rendered.

By signing below, I express my understanding and intent to enter this General Release, Waiver, Assumption of Risk and COVID-19 Release, Waiver, and Assumption of Risk knowingly and voluntarily.

ACKNOWLEDGEMENT

I understand and agree that submitting this application form does not automatically register me as a participant in the Palmdale Partners Academy and that I will be notified of acceptance into the class. By submitting this form, I attest that the information I have provided on the form is true and accurate.

ELECTRONIC SIGNATURE AGREEMENT

By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the same sense as a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at al later date.

By checking "I agree," you acknowledge and accept the terms of the Electronic Signature Agreement.

Participants Signature

Date

Parent/Guardian Signature

Date