Form Center

2. Participant's First Name*
3. Participant's Middle Name*
4. Participant's Last Name*
6. Gender*

   1. Female
   2. Male
7. Birthdate*
   Birthdate
8. Age*
10. Mailing Address*
12. Physical Address
14. City*
15. State*
16. Zip*
18. Email Address*
20. Parent/Legal Guardian's Name*
22. Phone Number (Home)*
23. Phone Number (Work)
25. Parent/Legal Guardian's Name*
27. Phone Number (Home)*
28. Phone Number (Work)
30. AGREEMENT, WAIVER AND RELEASE
    In consideration for being permitted by the Town of Mammoth Lakes (“Town”) to participate in the 2021 Camps and Programs containing all manner of sports, water-related activities, and outdoor programs to include hiking and climbing in Mammoth Lakes, Eastern Sierra (the “Activity”), I, the participant’s parent(s) or legal guardian, on behalf of the participant, his or her parent(s) or legal guardian, personal representatives, heirs, next-of-kin, executors, administrators, and assigns hereby waive, release, and discharge any and all claims for damages for personal injury, death, communicable diseases, illnesses, viruses or property damage which I, the participant, his or her parent(s) and legal guardian, personal representatives, heirs, next-of-kin, executors, administrators, and assigns may have, or which may hereafter accrue to me, the participant, or his or her parent(s) or legal guardian as a result of participation in said Activity. This release is intended to discharge, in advance, the Town, its officials, officers, employees, agents, volunteers, and contractors from any and all liability, claims, or causes of action arising out of or connected with said Activity or upon their acts or omissions, whether negligent or not. I, the participant, and his or her parent(s) and legal guardians, personal representatives, heirs, next-of-kin, executors, administrators, and assigns further covenant not to sue Town and its officials, officers, employees, agents, volunteers, and contractors from and for any and all liability for loss or damage to myself, participant, his or her parent(s) and legal guardian, and personal representatives, heirs, next-of-kin, executors, administrators and assigns, and from and for any account of injury to the person or property of myself, participant and his or her parent(s) and legal guardian and personal representatives, heirs, next-of-kin, executors, administrators and assigns, including death, whether caused by the negligence of myself, participant or his or her parent(s) or legal guardian, the Town, other participants or anyone else while participant participates in the activities, whether or not using Town property, equipment, supplies and apparatus, whether the risks are known or unknown to me, participant or his or her parent(s) or legal guardian. I, the participant, and his or her parent(s) or legal guardian agree to this agreement, wavier, and release on behalf of myself, participant, and his or her parent(s) and legal guardian and personal representatives, heirs, next-of-kin, executors, administrators, and assigns.
32. Parent/Legal Guardian Initial*
33. Date *
    Date
35. In agreeing to these statements, the participant and I, the participant’s parent(s) or legal guardian, are fully aware of the inherent dangers and risks associated with such Activity. These include, but are not limited to, strenuous activity which involves personal risks including bodily injury, physical impairment, death, and property damage; travel to and from special events; special skills required to perform certain activities; unknown or unseen facility conditions that could cause injuries; new movements or conditioning that may be required by an instructor to perform skills that the participant desires to learn or perform. I accept and assume full responsibility for any and all risks of damage, injury, or death resulting to myself, participant, and his or her parent(s) or legal guardians or arising out of my, participant’s, and his or her parent(s)’ or legal guardian’s actions while participating in the activities, whether or not while using Town property, equipment, supplies, and apparatus, whether the risks are known or unknown to myself, participant, and his or her parent(s) or legal guardian.
37. Parent/Legal Guardian Initial*
38. Date*
    Date
40. I hereby consent that
41. Partipant's Full Name*
43. may participate in the above Activity, and I state that said participant is physically fit and able to participate in said Activity. I hereby agree to defend, indemnify, save, and hold the Town, its officials, officers, employees, agents, volunteers, and contractors free and harmless from any and all liability from loss, liability, damage, cost, expense, or injury, including wrongful death, to any property or persons, including third parties, in any manner arising out of or incident to any acts, omissions, or willful misconduct of myself, participant, or his or her parent(s) or legal guardians while I, the participant, or his or her parent(s) or legal guardian participates in said Activity, whether or not while using Town property, equipment, supplies, and apparatus, including without limitation the payment of attorneys’ fees. Further, I shall defend at my own expense, including attorneys’ fees, the Town, its officials, officers, employees, agents, volunteers, and contractors in any action or proceeding, legal, administrative, or otherwise, based upon such acts, omissions, or willful misconduct.
45. Parent/Legal Guardian Initial*
46. Date*
    Date
48. I hereby acknowledge, understand, and agree that I have carefully read this agreement, waiver, and release and fully understand its contents. I hereby acknowledge, understand, and agree that I voluntarily sign this agreement, waiver, and release and further agree that no oral representations, statements, or inducements have been made by the Town, and further agree that this agreement, waiver, and release shall be binding on me, the participant, and our personal representatives, heirs, next-of-kin, executors, administrators, and assigns. I further acknowledge, understand, and agree that the participant is under 18, and will strictly abide by all safety requirements and other instructions given to him or her by any and all Town personnel and/or instructors during his or her participation in the Activity.
50. Parent/Legal Guardian Initial*
51. Date*
    Date
53. I HAVE CAREFULLY READ AND I UNDERSTAND, ACKNOWLEDGE AND AGREE TO THIS WAIVER AND RELEASE OF LIABILITY. I UNDERSTAND THAT I AM GIVING UP VALUABLE LEGAL RIGHTS BY SIGNING THIS FORM. I HAVE AGREED TO SIGN THIS FORM OF MY OWN FREE WILL. I UNDERSTAND THAT I MAY SEEK THE ADVICE OF AN ATTORNEY IN ANY MATTER CONNECTED WITH THIS FORM BEFORE SIGNING.
55. Parent or Legal Guardian's Name*
56. Date*
    Date
58. IMAGE RELEASE
60. I,
61. Parent or Legal Guardian's Full Name*
63. hereby consent to allow the exclusive use of, and relinquish all rights to, photographs and video in any manner including the likeness and/or activities of the participant and further authorize the Town of Mammoth Lakes, its agents or assigns, to make unlimited use of such reproductions, including but not limited to print and/or electronically on the internet with or without your name for any lawful purpose. I acknowledge that no compensation will be provided for such use by the Town of Mammoth Lakes. I understand that this Release shall remain in effect unless a subsequent written notification is provided to the Town of Mammoth Lakes.
65. Parent or Legal Guardian's Full Name*
66. Date*
    Date
68. Youth Transportation Waiver
70. I
71. Parent or Guardian's Full Name*
73. the parent of,
74. Participant's Full Name*
76. (“my child”), give permission for my child to participate in the Town of Mammoth Lakes Park and Recreation programs and camps that include transportation to and from the activity(ies.) I authorize the Town, to transport my minor child in a Town bus or other vehicle, driven by an individual authorized by the Town. I understand my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or staff or volunteer.
78. My Child Requires a booster seat*

    1. Yes
    2. No

    (All children under 8 years of age are required to be in a booster seat)
80. I have read, understand, and discussed with my child:*

    1. 1. My child will travel in a motor vehicle driven by an adult and my child is to wear their safety belt during travel;
    2. 2. My child is expected to listen to supervising staff/driver, respect staff and other children, the vehicles they ride in, and the people they travel with during the trip;
    3. 3. My child is to remain in their seat and not be disruptive to the driver of the vehicle.

    Must check all
82. I hereby release the Town, its employees, agents and volunteers, from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child while participating in or traveling to and from the events/activities.
84. Please initial each of the following statements.
86. Initials*
87. I recognize participation in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify I have been advised of the potential risks, and I have full knowledge of the risks involved in this activity, and I assume any expenses incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.
89. Initials*
90. I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms.
92. Initials
93. I have read this entire waver and authorization form, I fully understand its terms and conditions, and I agree to be legally bound by its terms.
95. Parent or Legal Guardian's Full Name*
96. Date*
    Date
98. PERSON TO CONTACT IN AN EMERGENCY
100. Emergency Contact Name*
101. Relation*
103. Address
105. City
106. State
107. Zip
109. Daytime Phone Number*
110. Evening Phone Number
112. CONSENT FOR MEDICAL TREATMENT OF MINORS
114. Physician's Name*
115. Physician's Phone Number*
117. Medication or Allergies (please list and explain)*
119. Limitations (please list and explain)*
121. I,
122. Parent or Legal Guardian's Name*
124. the parent or legal guardian of
125. Participant's Full Name*
127. authorize qualified physicians to render medical treatment or care that they may deem necessary for my child in case of illness or accident during the 2021 Camps and Programs in Mammoth Lakes, Eastern Sierra. In the event of injury to a child participant and if a parent cannot be reached, the local emergency services will be contacted to transport the injured to the nearest medical facility. By my signature below, I signify that I have read, understand, and voluntarily agree to be bound by each of the terms stated above.
129. Parent or Legal Guardian's Full Name*
130. Date*
     Date
132. 2021 CONCUSSION INFORMATION FACT SHEET
134. Why am I getting this Information Sheet?
     You are receiving this information sheet because of California state law AB 2007 (effective January 1, 2017), which applies to youth sports organizations that offer any of the following sports: baseball, basketball, bicycle motorcross (BMX), boxing, competitive cheerleading, diving, equestrian activities, field hockey, football, full contact martial arts, gymnastics, ice hockey, lacrosse, parkour, rodeo, roller derby, rugby, skateboarding, skiing, soccer, softball, surfing, swimming, synchronized swimming, volleyball, water polo and wrestling. The law requires:
136. 1. an athlete who may have a concussion during practice or game to be removed from the activity for the remainder of the day. 2. any athlete removed for this reason provide a written note from a medical doctor in the management of concussion before returning to practice 3. a concussion information sheet to be signed by the athlete and parent/guardian and returned to their league/team before an athlete can start the season and begin practice. 4. all coaches and administrators receive training about concussions annually
138. What is a concussion and how would I recognize one?
     A concussion is a kind of brain injury. It can be caused by a bump or hit to the head, or by a blow to another part of the body whereby the force of the blow shakes the head. Concussions can appear in any sport, and can look different in each sport. Most concussions get better with rest and over 90% of athletes fully recover. However, all concussion should be considered serious. If not recognized and managed the right way, they may result in problems including brain damage and even death. Most concussions occur without being knocked out. Signs and symptoms of concussions may show up right after the injury or can take hours to appear. If your child reports any symptoms of concussion or if you notice any symptoms, seek medical evaluation from a medical doctor trained in the evaluation and management of concussion. If your child is vomiting, has a severe headache, or is having difficulty staying awake or answering simple questions, call 911 or take him/her immediately to the emergency department of your local hospital.
140. What can happen if my child keeps playing with concussion symptoms or returns too soon after getting a concussion?
     Athletes with signs and symptoms of concussion should be removed from play immediately. There is NO same day return to play for a youth with a suspected concussion. Youth athletes may take more time to recover from concussion and are more prone to long-term serious problems from a concussion. Even though a traditional brain scan (e.g. MRI or CT) may be “normal”, the brain has still been injured. Animal and human research studies show that a second blow before the brain has recovered can result in serious damage to the brain. If your athlete suffers another concussion before completely recovering from the first one, this can lead to prolonged recovery (weeks to months), or even severe brain swelling (Second Impact Syndrome) with devastating consequences. There is an increasing concern that head impact exposure and recurrent concussions may contribute to long-term neurological problems. One goal of this concussion program is to prevent a too early return to play so that serious brain damage can be prevented.
142. Signs observed by teammates, parents and coaches may include:
     • Appears dazed or stunned • Confused about plays • Forgets instructions • Unsure of game, score or opponent • Moves clumsily or awkwardly • Answers questions slowly • Slurred speech • Shows a change in personality or behavior • Can’t recall events before or after the injury • Seizures • Passes out
144. Symptoms may include one or more of the following:
     • Headaches • Pressure in the head • Nausea • Neck pain • Has trouble standing or walking • Blurred, double or fuzzy vision • Bothered by light or noise • Feeling sluggish • Feeling groggy • Drowsiness • Change in sleep patterns • Loss of memory • Tired or low energy • Sadness • Nervousness • Irritability • More emotional • Confused • Concentration problems • Repeating the same question/comment
146. Concussion Danger Signs: In rare cases, a dangerous blood clot may form on the brain in a person with concussion. An athlete should receive immediate medical attention if after a bump, blow or jolt to the head or body they exhibit any of the following sign:
     • One pupil larger than the other • A headache that gets worse • Repeated nausea • Convulsions or seizures • Unusual behavior • Increasingly confused, restless or agitated • Drowsy or cannot be awakened • Weakness, numbness or decreased coordination • Slurred speech • Cannot recognize people or place • Loses consciousness, even briefly
148. How is Return to Play (RTP) determined?
     Following a concussion, athletes may have difficulties with short and long term memory, concentration and organization. They will require rest while recovering from the injury (e.g. avoid reading, texting, video games, loud movies), and may even need to stay home for a few days. As the athlete returns to normal they may benefit from a reduced schedule, depending on how they feel. If recovery from the concussion is taking longer than expected, a further reduction in activity may be beneficial and may require further assessment by a medical doctor trained in the management of concussion. Concussion symptoms should be completely gone before returning to competition. A RTP progression involves a gradual, step-by-step increase in physical effort, sports-specific activities and the risk for contact. If symptoms occur with activity, the progression should be stopped. If there are no symptoms the next day, exercise can be restarted at the previous stage. RTP after concussion should occur only with clearance from a medical doctor trained in the evaluation and management of concussions, and a step-by-step progression program monitored by an athletic trainer, coach or other authorized person. Californian law states that return to play (full competition) must be no sooner than 7 days after the concussion diagnosis has been made by a physician.
150. Final thoughts for Parents/Guardians:
     It is well known that athletes will often not talk about signs of concussion, which is why this information sheet is so important to review with them. Teach your child to tell the coaching staff if he/she experiences concussion symptoms, or if he/she suspects that a teammate has a concussion. You should also feel comfortable talking to the coaches or administrators about possible concussion signs and symptoms you may be seeing in your child.
152. For current and up-to-date information on concussions you can visit:
     https://www.cdc.gov/headsup/
154. I acknowledge that I have read the Town of Mammoth Lakes Concussion Information Sheet.
156. Participant's Full Name*
157. Date*
     Date
159. Parent/Legal Guardian's Full Name*
160. Date*
     Date
Leave This Blank:


164. 1. Receive an email copy of this form.
165. Email address

     This field is not part of the form submission.

166. Submit

* indicates a required field