Special Accommodations: To better serve you, please provide information regarding any special accommodations you may need. Reasonable accommodations can be made upon request. If special accommodations are needed please contact staff at 510-690-6624 or TTY/TDD 510-633-0460 to arrange. All information will be kept confidential.
Please feel free to add additional information below, or call the Lifeguard Services Assistant at 510.690.6624 to discuss any other issues.
Parent or Guardian Authorization:
I, the undersigned, as participant, or as parent or legal guardian of the child listed on this form, hereby assume full responsibility for all risk of injury or loss which may result from me or my child’ participation in the program listed below, and hereby agree to hold harmless, release and forever discharge The East Bay Regional Park District, it’s officers, directors, agents, and employees (collectively “District”) and their representatives, from any and all claims and demands whatsoever which the undersigned, and any of them or any third party and their representatives or any person acting under persons, or damage to, loss of or destruction of property arising or resulting directly or indirectly from my or my child’s participation in the aforementioned activity, and occurring said participation, or anytime subsequent thereto regardless of whether said claims or demands arise out of negligence on the part of the District. The terms of this release shall serve as a release and assumption of risk for myself, my child, heirs, executives, administrators, and for all of my family members.
I understand, agree, and acknowledge that some activities in this program may be hazardous nature and/or include physical and/or strenuous activity. I hereby assume all risk of such activities. Understanding this, I state to the best of my knowledge that I or my child listed on this form have no medical, physical, mental, or emotional health conditions which would hinder my or my child’s active participation in the program listed on this form.
In the case of any emergency in which I am not able to give permission for medical treatment and my designated emergency contact cannot be reached, I authorize the staff or agents of the District to obtain whatever medical treatment is deemed necessary for my child’s welfare. In the case of my child, this authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether my medical insurance would cover such charges and fees.
I give my full permission to East Bay Regional Park District and any other media sources to use my or my child’s name and any photographs, video graphs, motion pictures or recordings for any publicity and promotional purposes without obligation or liability to me.
