Release Form

VANGUARD YOUTH
Release Form
Effective August 2012- July 2013
Member’s Name:____________________________________ Gender: M F
Birth date:__________________________ Age:____________
Address:___________________________________________Phone #: ______________
Parent/Legal Guardian:_________________________________
Email Address:__________________________________________
Emergency Contact Person:___________________________ Phone #:_____________
Relationship to Member_______________________________
RELEASE, INDEMNIFICATION & HOLD HARMLESS: I, the undersigned, represent that I am the parent or legal guardian of the above mentioned child. I hereby recognize and acknowledge that there are inherent hazards and risks connected with certain activities and programs associated with the entity known as Vanguard Youth. The undersigned, on behalf of the above named child, knowingly and voluntarily assumes full responsibility for such risks and hazards. The undersigned is aware of the content of the programs and activities of Vanguard Youth and hereby represents that the undersigned member is physically, mentally and emotionally fit and capable of safely participating in such programs or activities. I agree as a condition of participation in programs or activities of Vanguard Youth, I will hold its officers, members, the property owner of where Vanguard is held and volunteers harmless from and against any and all loss, judgments, damage and expense incurred by reason of any claim or liability based upon (1) Personal injury (including death) or property damage to any person or building arising out of the negligent or intentional action of the undersigned member, or (2) Personal injury (including death) or property damage to the undersigned member, except to the extent that such injury or damage is directly intentionally caused by the acts or omissions of Vanguard Youth, its officers, members or volunteers.
Member Signature _____________________________________ Date ______________
Parent/Legal Guardian Signature___________________________ Date _____________