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ANAHEIM COMMUNITY SERVICES STATEMENT OF HEALTH AND CONSENT Program:_ Date:_ Child’s Name: Age:_ Date of Birth:_ Address:_ Zip:_ Home Phone: Parent’s Name:_ Cell:_ Work Parent’s Name:_ Cell: Work Phone: _ Email Address: Does the participant take any medication at the present time? Yes No If yes, what?_ Dosage_ PARTICIPANT MEDICATION GUIDELINES Medicine will be given out to participants under the following guidelines: 1. Medicine will be given once at lunchtime. 2. Medicine must be given to staff person in its original prescription container with a single dose. 3. Participants must be able to administer the medication themselves. I have read and understand the Participant Medication Guidelines. Signature:_ Date:_ B. ALLERGIES Does the participant have any allergies? If yes, please list? MEDICAL RELEASE - Please read and initial. 1. I hereby designate City of Anaheim employees to provide nonemergency medical/health services, and care for said minor. 2. I hereby designate City of Anaheim employees to authorize emergency medical/health services, and care for said minor. Note: Failure to initial #2 will bar participation in the program for said minor. PHOTO RELEASE I hereby give the City of Anaheim irrevocable right and permission, in connection with the photographs/negatives/videos taken of me, or in which I may be included with others, the following: I. The right to use and reuse, in any manner at all, said photographs/negatives/videos, in whole or in part, either by themselves or in conjunction with other photographs/negatives/ videos in any medium and for any purposes whatsoever, including all promotional and advertising uses as well as using my name in connection therewith if it is so desired; and 2. The right to copyright said photographs/negatives/videos in the photographer’s and/or the City of Anaheim’s name. a) I hereby forever release and discharge the City of Anaheim from any and all claims, actions and demands arising out of, or in connection with, the use of said photographs/negatives/ videos, including, without limitation, and all claims for invasion of privacy and libel. b) This release shall insure to the benefit of the assigns, licensees and legal representatives of the City of Anaheim as well as the party(ies) for whom photographs/negatives/videos were taken. I AM AWARE THAT PARTICIPATING IN THIS ACTIVITY CAN BE HAZARDOUS, AND I AM AWARE OF THE DANGERS INVOLVED WHICH MAY PLACE THE PARTICIPANT AT RISK FOR POSSIBLE INJURY, DEATH, OR PROPERTY DAMAGE AND I HEREBY AGREE TO ACCEPT, ON BEHALF OF MYSELF AN MY CHILD, ANY AND ALL SUCH RISKS. In exchange for the benefits derived by my child’s participation in the Anaheim Community Services Department’s program, I HEREBY AGREE TO INDEMNIFY, HOLD HARMLESS AND NOT SUE THE CITY OF ANAHEIM AND THEIR EMPLOYEES, REPRESENTATIVES, AGENTS, SERVANTS, OR VOLUNTEERS for any liability claims, or actions for injury, death, or damage to personal property arising out of or in conjunction with my child’s participation in Anaheim Community Services Department’s program from whatever cause including the active or passive negligence of the City of Anaheim, its officers, employees, agents and representatives. I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND SIGN IT OF MY OWN FREE WILL. Signature: Date: A. PARTICIPANT MEDICATION The person in charge of the program must be notified if medicine is brought to the program. At any time if something should happen to the participant that would alter this health history, prior to or during the program, contact the staff immediately to update this form. Please list the individuals who are allowed to pick up your child from this program: