PARENT/GUARDIAN PERMISSION SLIP AND LIABILITY WAIVER

Burrage Mansion, Park, and Generic Field Trips This permission slip gives my child permission to participate at:

Burrage Mansion

Park Field Trips

Generic Field Trips

I HERBY GRANT PERMISSION FOR MY CHILD____________________________________

TO ACCOMPANY AN AUTHORIZED STAFF OR VOLUNTEER MEMBER OF THE BOYS & GIRLS CLUB

ON ANY AUTHORIZED SPECIAL EVENTS, COMMUNITY SERVICE, OR FIELD TRIP ACTIVITIES. I FURTHER WAIVE ANY CLAIM TO LIABILITY OR COMPENSATION ON THE PART OF SAID STAFF

OR VOLUNTEER OF THE BOYS & GIRLS CLUB FOR ANY INCIDENT OR ACCIDENT WHICH MAY

OCCUR TO MY CHILD WHILE ENGAGED IN THESE ACTIVITIES.

MEDICAL CONSENT

I FURTHER AUTHORIZE BOYS & GIRLS CLUB STAFF OR VOLUNTEER TO SECURE ANY

EMERGENCY MEDICAL CARE NEEDED AS A RESULT OF ANY INCIDENT OR ACCIDENTAL

OCCURRING TO MY CHILD WHILE ENGAGED IN ANY BOYS & GIRLS CLUB ACTIVITY.

__________________________ _________________________________________

DATE PARENT/GUARDIAN SIGNATURE

__________________________

MEMBER BIRTHDATE

Destination 1: Burrage Mansion Destination 2: Texonia Park Destination 3: Generic Field Trips (these locations vary throughout the summer. Payment must be received at least one day prior and field trips are filled on a first-come, first-served basis) Date: Varies. See Pamphlet for full listing Time: Varies. See Pamphlet and calendar at front desk for times

Parent/Guardian Name: ____________________________________________________________

Parent/Guardian Emergency Phone #:___________________________________________________

Boys & Girls Facilitating Staff: Jenna Goldman, Vanessa Senteno

(909) 798-4599 1251 Clay St.

Redlands, CA 92374

Swimming Pool/Beach/Waterpark Use

Acknowledge of Risk Waiver and Release of Liability

In consideration of my use of athletic facilities, I hereby forever release and covenant not-to-sue the Boys & Girls Clubs of Greater Redlands-Riverside, its Trustees, employees, instructors, volunteers, agents, and all others who are involved, from any and all present and future claims resulting from ordinary negligence on the part of the Boys & Girls Clubs of Greater Redlands-Riverside or others listed for property damage, personal injury, or wrongful death, arising as a result of my engaging in or receiving instruction in pool use, beach, and waterpark activities or any activities incidental thereto, wherever, whenever, or however the same may occur. I hereby voluntarily waive any and all claims both present and future, resulting from ordinary negligence, that may be made by me, my family, estate, heirs, estate or assigns, and I relinquish on behalf of myself, spouse, heirs and assigns the right to recover for injury or death.

I am aware that swimming, other pool, beach, and waterpark activities are vigorous and can involve severe cardiovascular stress. I understand that swimming, other pool, beach, and waterpark activities, involve certain risks, including but not limited to death. In addition, I understand that participation in swimming pool use, waterpark and beach involves activities incidental thereto, including, but not limited to, the possible reckless conduct of other participants. All stresses and hazards associated with this activity cannot be foreseen.

I will voluntarily use pool facilities, beach, and waterpark activities with knowledge of the danger involved and hereby agree to accept any and all risks of property damage, personal injury, or death.

I have a personal responsibility to follow any safety rules and procedures established by the Boys & Girls Clubs of Greater Redlands-Riverside and that are associated normally with swimming and other pool use activities.

I further agree to indemnify and hold harmless the Boys & Girls Clubs of Greater Redlands-Riverside and others listed for any and all claims arising as a result of my participation in pool activities, swimming, beach, and waterpark activities or any activities incidental thereto, wherever, whenever, or however the same may occur.

I understand that this waiver is intended to be as broad and inclusive as permitted by the laws of the State of California, and I agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for any legal proceedings shall be in the State of California.

If I am at least 18 years of age, I affirm that I am signing this agreement solely and freely. If I am under 18 years of age, I will also obtain the signature of my parent or guardian. I have read this form and fully understand that by signing this form, I am giving up legal rights and/or remedies which may be available to me for the ordinary negligence of the Boys & Girls Clubs of Greater Redlands-Riverside or any of the parties listed above. I understand that this agreement is a binding legal document.

For persons under the age of 18, the parent or guardian who signs below also commits to the participant conditions of this agreement.

CAUTION: READ THIS DOCUMENT CAREFULLY BEFORE SIGNING:

(Signature of Parent or Participant) Date signed (Printed Name of Participant)

(Signature of Witness) Date sign

MOBILE VISION SERVICES CONSENT AND RELEASE FORM

***There is no cost for your child to participate in the program.***

Dear Parent/Guardian,

Vision To Learn is a nonprofit that offers vision screenings, eye exams and glasses to kids at no cost. Vision To Learn will be bringing its mobile vision care clinic to your child’s club to provide vision screenings, eye exams and glasses to children who need them. If you would like to give your child permission to participate in the Vision To Learn program, please complete and sign this form. Return the completed form to your child's Boys & Girls Club.

PLEASE PRINT OR TYPE:

CONTACT INFORMATION: Street Address: Unit/ Apt:

City: State: Zip:

Phone Number: Emergency Phone Number: Email:

Vision To Learn sometimes collects images of children they serve in order to publicize their programs. By signing this form you agree that your child may be photographed, filmed, and/or voice recorded in any format (collectively called “Recordings”) and that Vision To Learn own and may use such recordings in any format without compensation to your child or your child’s parents or guardians. You agree that you are waiving any and all claims against Vision To Learn or Boys & Girls Club of America that may arise from your child’s participation in the program or the use of the Recordings.

By signing this form, I agree to allow my child to receive vision care services through Vision To Learn’s mobile vision clinic. I acknowledge that I have the right to refuse any services provided by Vision To Learn but that I am choosing voluntarily for my child to receive vision services. Vision To Learn provides a modified screening exam with a full refraction. Vision To Learn is able to provide glasses to students who need them, but does not provide comprehensive eye exams or dilation. I understand that receiving vision services provided by Vision To Learn’s mobile clinic will constitute a routine vision examination and eyeglasses that may be billed to my (child’s) Medicaid benefits. Additional exams are available based on medical eye care needs on a referral basis. I agree that I am waiving any and all claims against the Boys & Girls Club of America that may arise from my child’s participation in the program. My signature shows that I have read and understood this voluntary Consent and Release and I agree to its provisions.

YES, I agree to allow my child to participate in the Vision To Learn mobile vision clinic program, described above.

Parent/ Guardian Signature: Date:

Parent/ Guardian First Name:

FEMALE Child’s Gender (please check one):

MALE

Parent/ Guardian Last Name:

Year Date Child’s Date of Birth: Month

REQUIRED: Child’s Last Name: Child’s First Name:

SERVICIOS MÓVILES DE VISIÓN

***La participación de su hijo/a en el programa no tiene costo.*** Estimado Padre/Tutor,

Vision To Learn es una organización sin fines de lucro que ofrece exámenes de visión, exámenes oculares y anteojos a niños sin costo alguno. Vision To Learn llevará su clínica móvil de visión al club de su hijo/a para ofrecer exámenes de visión, exámenes oculares y anteojos a los niños que lo requieran. Si desea dar permiso para que su hijo/a participe en el programa de Vision To Learn, por favor complete y firme este formulario. Devuelva el formulario llenado al Club Boys & Girls de su hijo/a.

LLENE EN LETRA DE MOLDE:

INFORMACIÓN DE CONTACTO: Dirección: Unidad/ Apartamento:

Ciudad: Estado: Código postal:

Teléfono: Teléfono emergencia: Correo electrónico:

Vision To Learn a veces recolecta imágenes de los niños a quienes sirve para promocionar sus programas. Al firmar este formulario, acepta que su hijo/a sea fotografiado, filmado o se grabe su voz en cualquier formato (en su conjunto denominados las "Grabaciones") y que Vision To Learn es propietaria y puede usar tales grabaciones en cualquier formato, sin ninguna compensación para el niño o niña o los padres o tutores del niño o niña. Usted acepta que renuncia a cualquier y todos los reclamos contra Vision To Learn o Boys & Girls Club of America que puedan surgir de la participación de su hijo/a en el programa o el uso de las Grabaciones.

Al firmar este formulario, acepto que mi hijo/a reciba servicios de cuidado de la visión en la clínica móvil de visión de Vision To Learn. Reconozco que tengo el derecho a rechazar cualquier servicio provisto por Vision To Learn pero que voluntariamente escojo que mi hijo/a reciba los servicios de visión. Vision To Learn provee un examen de revisión modificado con refracción completa. Vision To Learn puede proveer anteojos a los estudiantes que los necesiten, pero no ofrece exámenes oculares extensos o dilatación. Entiendo que el hecho de recibir servicios de visión provistos por Vision To Learn en su clínica móvil constituye un examen runtiario de la vista que puede ser facturado a los Beneficios de Medicaid de mi hijo/a. También se pueden proveer exámenes adicionales, de acuerdo a las necesidades de cuidado ocular, con una referencia. Acepta que renuncio a cualquier y todos los reclamos contra Vision To Learn o Boys & Girls Club of America que puedan surgir de la participación de mi hijo/a en el programa. Mi firma prueba que he leído y entendido este Consentimiento Voluntario y Renuncia y acepto sus condiciones.

SÍ, acepto y permito que mi hijo/a participe en el programa de la clínica móvil de visión de Vision To Learn, como se describe arriba.

Firma Padre/Tutor: Fecha:

Nombre Padre/Tutor:

FEMENINO Sexo niño/a (seleccione uno):

MASCULINO

Apellido Padre/Tutor:

Año Día Fecha de nacimiento: Mes

OBLIGATORIO: Apellido niño/a: Nombre niño/a: