"Education Through AdventureCity Kids' Adventures PermissionHold"
Education Through Adventure/City Kids’ Adventures Permission/Hold Harmless Agreement I give permission for myself/son/daughter _______________________________ to participate in The Adventure Education Program with the Youth Services Bureau. The program consists of the Adventure Ropes Course at Scalzi Park, canoeing in Holly Pond, mountain biking, rock climbing, multiday backpacking trips, and hiking. I also give permission for my child/myself to be transported to and from adventure course to special activities. I will hold harmless, the City of Stamford, its agents and employees from and against all claims, damages, losses and expenses, including attorney’s fees arising out of and resulting from any accident while participating in the adventure activities. Photographs may be taken during the program and used for publicity purposes. Parents / participants should consider any medical or emotional condition of the participant, which raise concerns about the participant’s involvement in adventure activities. Signature of Participant or Parent/Guardian _________________________________________Dated ___________ Home Address ____________________________________________City _____________________ ST _____ZIP ___________ Home Phone _____________________ Work Phone ________________________ Cell Phone____________________________ MEDICAL INFORMATION Physician’s Name_____________________________________________________________Phone ___________________ Health Care Provider _________________________ Policy # ______________________Group # ____________________ Please list any chronic illness, medical conditions, allergies or medication being taken by participant. If none, state none. MEDICAL AUTHORIZATION I hereby authorize the instructors of the Mayor’s Youth Services Bureau to seek emergency medical treatment for the participant named above in the event that a parent or legal guardian cannot be reached at the above telephone numbers at the time of an emergency. Signature of Participant or Parent/Guardian __________________________________________Dated ____________ EMERGENCY CONTACTS IF PARENTS CANNOT BE REACHED: _____________________________________________________________________________________________________ Name Home Phone Work Phone Cell Phone Relationship to Child ________________________________________________________________________________________________________________________________ Name Home Phone Work Phone Cell Phone Relationship to Child Group (Office Use Only):__________________________________________________