This is to authorize the release of the information contained on this form to Liberty City Optimist Club of Fl. Inc. I certify that this information is true,
and I understand that giving false information may result in my child being disqualified and/or ineligible. I understand that this information is for
statistical purposes only and will be kept confidential as stipulated in the Federal Privacy act of 1968. I also understand that I may be contacted by a
representative from one of the funding sources below to verify services provided.
CONSENT FOR MEDICAL TREATMENT (MINOR)
As the parent or legal guardian of the participant, I hereby give my consent for emergency medical care prescribed by duly licensed doctor of
medicine or doctor of dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my
As parent/guardian of the participant, I understand that the Liberty City Optimist Club insurance is a secondary insurance policy. If I have no family
insurance, then and only then will the Liberty City Optimist Club of FL Insurance apply.
applicable for injuries incurred during Liberty City Optimist Club activities only.
I/We, the parent(s) / guardian(s) of understand that the
Liberty City Optimist Club makes available organized athletic, recreational and educational activities for boys and girls. I/We understand that there
are always dangers and risks connected with participation in such activities (particularly contact sports) and, as parent/guardian of the participant
named above, I/We hereby give my/our approval of his/her participation only upon the condition of my/our acceptance of responsibility for any and
such risks and dangers (including any risks associated with transportation to or from the Club or any Club activities) and I/we do hereby release,
indemnify and hold harmless the Liberty City Optimist Club, members, employees, organizers, sponsors and supervisors of all its activities, from any
person transporting him/her to or from any Club or activity.
I/We hereby give my/our approval for the Liberty City Optimist Club of Florida, Inc. to take and/or use photographs, prints and the likeness of my son
and/or daughter in any promotion materials and releases and hold harmless the Liberty City Optimist Club of Florida, Inc. its members, employees,
associates, personnel, affiliated organizations, so long as photographs and/or prints are used for the purpose and goals of the Liberty City Optimist
Club of Florida, Inc.
PARENT/GUARDIAN EQUIPMENT RESPONSIBILITY
It is further agreed that all equipment and uniforms supplied by Liberty City Optimist Club shall remain the property of said organizations, unless agreed upon by said organization and shall be property cared for by the participant and shall be returned in same condition as issued to participant
except for normal wear and tear. Parents/Guardians are responsible and agree to pay replacement value for any damage or loss of equipment.
I Agree All Terms & Conditions