Jewish Community Center of Dallas

Aaron Family JCC • 7900 Northaven Road• Dallas, Texas 75230-3392 • 214-739-2737 • Fax 214-368-4709 


Youth Release Form

Date*
Child Name*
Date of Birth*
Gender*
Does your child have any allergies, illnesses, medications, or injuries that we should be aware of?*
Do you have another child to add?
Child 2 Name*
Child 2 Date of Birth *
Child 2 Gender*
Does your child have any allergies, illnesses, medications, or injuries that we should be aware of?*
Would you like to add a third Child?
Child 3 Name*
Child 3 Date of Birth*
Child 3 Gender*
Does your child have any allergies, illnesses, medications, or injuries that we should be aware of?*
Home Address*
Parent 1 Name*
Parent 2 Name
Non-Custodial Parent's Address (if applicable)

Insurance Information

AUTHORIZATION FOR EMERGENCY

WHEN NO PARENT CAN BE REACHED, THE FOLLOWING MAY ACT IN MY BEHALF AND MY CHILD MAY BE RELEASED TO (Individuals listed below may have access to health information about my child): 

Name
Name
Physician Name*

I give my permission for child/children to participate in all activities of the Jewish Community Center of Dallas, including swimming and field trips (if applicable). I understand that on field trips my child/children will be transported by bus or private automobile.(Required to participate in any camp programming)

Use your mouse or finger to draw your initials above

I hereby grant the J permission to use the name, likeness, personal success story and photographs, films and videotapes of me and other members of my family for the purpose of publicizing the J. This permission includes, but is not limited to, identification of the members of my family by pictures and/or name in printed materials, newspapers and magazine articles, radio and television broadcasts on the J’s website.

Use your mouse or finger to draw your initials above

In the event of an emergency which affects the health of the student, I undersigned, do hereby authorize officials of the JEWISH COMMUNITY CENTER to contact directly the persons named on this card and if neither parent nor guardian can be contacted, I authorize the named physician to render such treatment as may be deemed necessary in an emergency, for the health of the child. I hereby give the personnel of the Jewish Community Center of Dallas permission to make arrangements for emergency medical attention, to transport the student to an accredited facility for diagnosis and treatment and to authorize administration of medication as necessary. I request and authorize physicians, dentists and staff of the accredited medical facility to perform any diagnostic procedures, treatment procedures, x-ray treatments and administration of anesthetics as may be necessary in the diagnosis and treatment of minor student. I understand that I have not been given a guarantee as to the results of examination or treatment. I agree to pay for the services rendered and expenses incurred pursuant to this authorization. Further, I will not hold the Jewish Community Center or their Officers, Directors, Administrators, Teachers, Personnel or Employees financially responsible for the emergency care and/or transportation for said child. The authority granted herein will expire one year from acknowledged date. 

Use your mouse or finger to draw your signature above

PARTICIPANT WAIVER AND RELEASE OF LIABILITY: READ BEFORE SIGNING


Organization Name: Jewish Community Center of Dallas, Inc. (the "J")

In consideration of being allowed to participate in any way in any program, virtual or onsite related events and activities at the J or sponsored by the J (“programs”) I on my own behalf and on behalf of any minor children I am responsible for appreciate and agree that: 

  1. The risk of injury from the activities involved in programs offered by the J, virtual or onsite, may be significant, including the potential for permanent injury or even more serious consequences, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist, and; 
  2. On my own behalf and on behalf of any minor children for whom I have responsibility, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROH lliE NEGLIGENCE OF THE J, other than "gross negligence" as defined by Texas law, and those affiliated with the J described in Paragraph 5 or others, and assume full responsibility for my and my minor children's participation. If anyone in my family violates any rule or policy of the J or otherwise causes a problem that in the sole discretion of the J CEO endangers the health, safety or welfare of anyone, the CEO may suspend my family's privilege to be on the J campus and participate in the J's programs, and; 
  3. Coronavirus / COVID-19 Warning & Disclaimer: Coronavirus a/k/a COVID-19 is an extremely contagious virus which spreads easily through person-to-person or other contact. Federal and state authorities recommend social distancing as a mean to prevent the spread of the virus. COVID-19 can lead to severe illness,. personal injury, permanent disability, and death. Participating in programs or activities upon the J premises could increase the risk of contracting COVID-19. The Jin no way warrants that COVID-19 infection will not occur through participation in programs or activities upon the J premises. 
  4. I willingly agree to comply with the stated and customary terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself and my minor children from participation and bring such to the attention of the nearest official immediately.
  5. I, for myself and on behalf of my minor children, heirs, assigns, personal representatives and next of kin, HEREBY WAIVE, RELEASE, INDEMNIFY, AND HOLD HARMLESS THE J, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, and, if applicable, owners and lessors (referred to as .. Releases") FOR All CLAIMS other than "gross negligence" as defined in Texas law in connection with any conduct regarding any program at the J or any activity sponsored by the J WITH RESPECT TO ANY AND All INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. 

I HAVE READ THIS WAIVER AND RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Use your mouse or finger to draw your signature above

This is to certify that I, as parent/guardian with legal responsibility for the previously named Participant on behalf of the participant do consent and agree to his/her waiver and release as provided above of all the Releasees, and, for myself, my spouse or co-guardian, heirs, assigns, and next of kin, waive, release and agree to indemnify and hold harmless the Releasees from any and all liability, other than “gross negligence” as defined by Texas law, associated with my minor child’s involvement or participation in these programs, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law 

Use your mouse or finger to draw your signature above
Powered by Formstack Create your own form