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Kiwanis

Costa Mesa
Participation Form
Child Name has my permission to participate in the following. Activity on Date Kellys Closet August 25, 2012

I agree to waive all claims against the Kiwanis Club of Costa Mesa (Kiwanis) and hold Kiwanis, its officers, agents and employees, harmless from any and all liability or claims, which may arise out of or in connection with my childs participation in this activity This waiver shall not apply to any occurrences which may arise solely out of the negligence of Kiwanis, its employees or agents.

Signature of parent/guardian Print name of parent/guardian Phone number

Photographic Authorization and Release


I_____________________, residing at ____________________________ have executed this Authorization and Release effective __________________, 20______.... For valuable consideration, the receipt and sufficiency of which is acknowledged, I hereby agree as follows: 1. I hereby irrevocably consent and authorize Kiwanis Club of Costa Mesa, Inc. (Kiwanis), its officers, directors, agents, representatives, employees, successors, and assigns, and any person, entity, organization, or association acting under their permission or authority, including, but not limited to, clients, suppliers, producers, publishers, photographers, and distributors to use, reproduce, distribute, display publicly, perform publicly, transmit electronically, and to prepare derivative works based upon the photographs and/or recordings attached hereto as an Appendix (Photographs and/or Recordings), in whole or in part, severally or in conjunction with other photographs or recordings in any medium and for any lawful purpose whatsoever, including, but not limited to, audiovisual works, publications, displays, exhibitions, illustrations, promotion, advertising, sale, or trade without any further compensation to me or the above-names child. 2. I hereby waive any right to inspect or approve the Photographs and/or the Recordings, the eventual use of the Photographs and/or the Recordings, or any works in which the Photographs and/or Recordings may eventually be used. 3. I hereby irrevocably consent to and authorize the use of above childs first name or a fictitious name in connection with the Photographs and/or Recordings or any derivative which is prepared therefrom in whole or in part. 4. I hereby release, discharge, and agree to hold harmless Kiwanis, its agents, representatives, employees, and any person acting under its permission or authority from any liability based upon or arising out of the use, reproduction, distribution, display, performance and electronic transmission of the Photographs and/or Recordings, in whole or in part, and any derivative thereof, whether or not any person acting on behalf of or on authority of Kiwanis was negligent. 5. I have read this Authorization and Release and understand its provisions. I have had the opportunity to ask questions concerning its terms and have had anything I questioned explained to me. I have no reservations concerning the terms of this Authorization and Release. This Authorization and Release shall be binding upon my heirs, successors, assigns, and legal representatives. 6. I am a parent or the legal guardian of the person named above. I have read this Authorization and Release and understand its provisions. I have had the opportunity to ask questions concerning its terms and have had anything I questioned explained to me. I have no reservations concerning the terms of this Authorization and Release. I hereby consent and agree to the foregoing terms and provisions on behalf of the person who is named above.

Signature

Typed or Printed Name

Date


Address, City, State, Zip code

WITNESS:

Signature

Typed or Printed Name

Date

Kiwanis Club of Costa Mesa


Medical Form
During all times when your child, __________________________________________ (insert childs fullname), is in the care of the Kiwanis Club of Costa Mesa, the Kiwanis Club will use reasonable care and reasonable means and their best judgment to insure your childs health, safety and welfare. In case of emergency, the person listed below will be contacted as quickly as possible. The undersigned agrees that the following medical history is accurate and that it will be updated as necessary.
Signature of parent/guardian Print name of parent/guardian Emergency contact name Relationship to child Phone number Alternate emergency contact name Relationship to child Phone number

Phone number

Medical History
Childs Name Address City, State, ZIP Health Insurance Company Group Name on Policy Telephone number or other contact information shown on insurance card Will your child be taking any prescription medication or over-the-counter drugs of any type? If yes, please explain Yes No Policy Number Sex: Age Male Female

Has he/she ever been or currently being treated for Nervousness? Heart Condition? Rheumatic Fever? Headaches? Asthma? Allergies to medication? Yes Yes Yes Yes Yes Yes No No No No No No Convulsion or epilepsy? High Blood Pressure? Cancer or Tumors? Fainting Spells? Diabetes? Other medical conditions? Yes No Yes No Yes No Yes No Yes No Yes No

List any allergies or other medical conditions of which we need to be aware