Oakdale Neighbors

Youth Mentoring

Child’s name: ______Date of Birth ______

Child’s Parent/Guardian______Date of Birth ______

Parent’s Drivers license ______

Address______

City______Zip______(email)______

Phone # (home) ______(work/cell) ______

Best time to call (home)______(work)______

Person to contact in case of emergency ______

Phone # ______

Physician Name and Phone Number______

Health Insurance Carrier______Policy #______

Does your son/daughter take any medications? Yes No (if yes, please list)______

Does your son/daughter have any medical conditions that would affect him participating in activities? Yes No (if yes, please explain) ______

______

Are there activities that your son/daughter should not participate in?Yes No (if yes, please explain) ______

______

Please return to:

Youth Director

Oakdale Neighbors

1260 Kalamazoo SE

Grand Rapids MI 49507(616) 248-2848 fax (616) 452-1763


Oakdale Neighbors

Parent/Guardian Consent form

I, ______, am the parent or legal guardian of ______(hereinafter "my child"), and I am informed of the activities offered by Oakdale Neighbors located at: 1260 Kalamazoo SE, in the City of Grand Rapids, County of Kent, and State of Michigan, beginning on the day______.As the parent or legal guardian of my child, I hereby consent for my child to attend and participate in all activities provided by Oakdale Neighbors.

IT IS MY INTENTION BY THIS AGREEMENT TO EXEMPT AND RELIEVE OAKDALE NEIGHBORS AND ITS OFFICERS, AGENTS, SERVANTS OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH OF MY CHILD CAUSED BY ANY ACT OF NEGLIGENCE OF OAKDALE NEIGHBORS AND ITS OFFICERS, AGENTS, SERVANTS OR EMPLOYEES.

By signing below, I indicate that I have read this document carefully, that I understand and agree to its terms, that I recognize that it constitutes a waiver of legal rights, and that it is enforceable to the extent allowed by law:I hereby declare the information provided is true, correct and complete to the best of my knowledge. I understand that any misstatement or omission of fact on this application will be considered cause for my dismissal.I understand that I or my child may be photographed, video/audio recorded, and/or interviewed for program promotion, recognizing that information may be used on the web, television, radio, or in print.

For and in consideration of permitting my child to observe, or use any facility or equipment of Oakdale Neighbors, or engage in and/or receive instruction in any activity or activity incidental thereto SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at Oakdale Neighbors, I hereby voluntarily and absolutely release, discharge, waive and relinquish any and all loss or damages or actions or causes of action for personal injury, property damage or wrongful death occurring to my child as a result of my child's observing or using facilities or equipment of Oakdale Neighbors, or engaging in or receiving instructions in any activities SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue.

I, my heirs, executors, administrators or assigns, agree that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against Oakdale Neighbors or its officers, agents, servants or employees, I will indemnify and hold harmless Oakdale Neighbors and its officers, agents, servants or employees from any and all claims or causes of action by my child or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will I present any claim against Oakdale Neighbors and said persons for personal injuries, property damage, wrongful death or otherwise, caused by any act of negligence by Oakdale Neighbors and said persons.

I have read this Release, have requested and have been provided with, or have requested and declined advisement on the potential dangers/risks of engaging in the observation, activities or instruction offered, assume all risks associated with such dangers and risks, and am fully aware of and understand the terms and the legal consequences of the signing of this Release. I intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

______DATED: ______

SIGNATURE OF PARENT OR GUARDIAN FOR ______

(Name of my child)