A/B Group (Ages 11-16)

A/B Group Registration: 2019

A/B Group (ages 12-16) - $350
8- week session June 17– August 8
(Mon/Wed/Fri) 9am-12pm
(Guests - $420)

Please don't register until your child has completed the tryout swim. Even returning Junior Guards must complete a tryout swim in 2019.

We are very much looking forward to having you in our program for the summer. Please answer the following questions. We hope you are having a wonderful school year and I look forward to seeing you soon!

A/B Group Registration 2019

* Indicates required field

Name *

First

Last

Member or Sponsor LMVA ID Number *

Email *

Street Address *

City *

Zip Code *

State *

Phone *

Age at Start of Program *

Years in Program *

Gender *

Male Female

T SHIRT SIZE (2 Included with registration fee) *

LAKE MISSION VIEJO ASSOCIATION
AUTHORIZATION TO TREAT MINOR
& PERMISSION TO PARTICIPATE IN EXCURSIONS/FIELD TRIPS

The minor whose name is listed below has my permission to participate in all activities with the Junior Lifeguard Program, including scheduled meeting times, excursions and trips. The undersigned agrees to hold the Lake Mission Viejo Association, its officers and employees thereof, harmless from any claim for injury to the below named minor arising out of or in any way connected with the program, excursions or trips. (The Association will not be held responsible in case of an accident.)

I (we) the undersigned parent, parents or legal guardian of *

a minor (‘Minor”), do hereby authorize and consent to Lake Mission Viejo Association, a corporation (“Authorized Party”), obtaining for Minor any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital or emergency care facility (“Medical Facility”) care to be rendered to Minor under the general or special supervision of any member of the Medical Facility staff or upon the advice of a Physician and Surgeon licensed under the provisions of the Medical Practice Act or a Dentist licensed under the provisions of the Dental Practice Act and on the staff of any Medical Facility holding a current license to operate from the State of California. It is understood that this authorization is given in advanced of any specific diagnosis, treatment, or Medical facility care being required and, except as expressly limited below, is given to provide authority and power to render care which a Physician and Surgeon or Dentist in the exercise of his/her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned by telephone at the numbers listed below prior to rendering treatment to Minor, but that any of the above treatment will not be withheld if the undersigned cannot be reached. If the Authorized Party is a corporation this authorization shall include any offer, director, or employee of said corporation or its affiliates. It is further understood that I (we) the undersigned are responsible for all charges for the above mentioned diagnosis, treatment or hospital care.

THIS AUTHORIZATION IS GIVEN PUSUANT TO THE PROVISIONS OF SECTION 25.8 OF THE CIVIL CODE OF CALIFORNIA.

Printed Name of Parent or Guardian* *

Parent/Guardian 1 *

Parent/Guardian 2 *

Date *

Physician name *

Phone Number *

Is the participant covered by family medical/hospital insurance? *

Yes No

Insurance Company: *

Policy Number: *

Group Number: *

Insurance Address *

Line 1

Line 2

City

State

Zip Code

Country

THIS CONSENT SHALL REMAIN IN EFFECT UNTIL AUGUST 31, 2019 Lake Mission Viejo Junior Lifeguards
Medical Information

Child's Date of Birth *

Siblings also in Program: *

In an emergency, notify:* *

Phone Number *

Additional Emergency Contact Name *

Phone Number *

Are there any extenuating circumstances the Lifeguards should be aware of concerning child custody or emergency procedure?* *

Yes No

Please Explain *

ALLERGIES
List all known. Do NOT leave blank. If no allergies please write- “no known allergies”
Please list allergy, reaction, and management of the reaction.

Allergies *

MEDICATIONS BEING TAKEN
Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely, even those taken outside of program hours. Please also identify any medications taken during the school year that the participant does/may not take during the summer.
This person takes NO MEDICATION on a routine basis. OR This person TAKES MEDICATION as follows:

Medication 1 *

Time Taken Each Day: *

Dosage *

Reason for Taking *

Medication #2 *

Time Taken Each Day: *

Dosage *

Reason for Taking *

Use this space to provide additional information about the participant’s behavior and physical, emotional, or mental health about which the camp should be aware. *

WAIVER & RELEASE OF LIABILTY: “I RECOGNIZE THAT THE JUNIOR LIFEGUARD PROGRAM IS DANGEROUS AND CONTAINS RISK OF PERSONNEL INJURY, DEATH, DISABILITY, PROPERTY DAMAGE OR LOSS (“DAMAGES”). I ASSUME ANY AND ALL RISKS associated with my child’s participation in the Lake Mission Viejo Junior Lifeguard Program, including, but not limited to, strenuous physical activity or exertion; striking or being struck by objects or persons; slipping; and exposure to heat, cold, and humidity. Such risks may result in injuries that include, but are not limited to, sprain, strain, or tear of muscles or ligaments; fracture or dislocation or joints or bones; head or facial injuries; spinal cord or internal injuries; or drowning. I know that these risks, hazards, and dangers include, but are not limited to, falling, slipping, or colliding with other users, staff or spectators. I understand that these risks, hazards, and dangers are further increased when other persons, whether or not of the same level of experience, are present at the same time using the same facilities. ALL SUCH RISKS ARE KNOWN AND APPRECIATED BY ME.”

Printed Name of Parent or Guardian *

Date *

VIDEO-PHOTO RELEASE
I give the Lake Mission Viejo permission to make photographs, videotapes, films or other likenesses of me, my child or legal ward. I hereby grant to Lake Mission Viejo the unrestricted right to copyright any of the above-mentioned materials containing images of me, as well as the unrestricted right to use and reuse them, with their caption information, in whole or in part, in any manner, for any purpose and in any medium now known or hereinafter invented. These rights include, but are not limited to, the right to publish, copy, distribute, alter, license and publicly display these materials and images for editorial, trade, marketing and/or advertising purposes, I also grant to Lake Mission Viejo and its licensees the unrestricted right to use and disclose my name in connection with use of the above materials.

I understand and agree that I will not be paid for any use described above.

I also waive, and release and discharge the Lake Mission Viejo, its officers, employees and/or agents from, any and all claims arising out of or in connection with any use of the materials , caption information and images described above, including any and all claims for libel, defamation and/or invasion of privacy or publicity. I realize I cannot withdraw my consent after I sign this form and realize this form is binding on me and my heirs, legal representative and assigns.

Printed Name of Parent or Guardian* *

Date *

Submit

A/B Group Registration

A/B Group Registration 2019

LAKE MISSION VIEJO ASSOCIATION AUTHORIZATION TO TREAT MINOR& PERMISSION TO PARTICIPATE IN EXCURSIONS/FIELD TRIPS

THIS AUTHORIZATION IS GIVEN PUSUANT TO THE PROVISIONS OF SECTION 25.8 OF THE CIVIL CODE OF CALIFORNIA.

THIS CONSENT SHALL REMAIN IN EFFECT UNTIL AUGUST 31, 2019 Lake Mission Viejo Junior LifeguardsMedical Information

ALLERGIESList all known. Do NOT leave blank. If no allergies please write- “no known allergies” Please list allergy, reaction, and management of the reaction.

​

LAKE MISSION VIEJO ASSOCIATION
AUTHORIZATION TO TREAT MINOR
& PERMISSION TO PARTICIPATE IN EXCURSIONS/FIELD TRIPS

THIS CONSENT SHALL REMAIN IN EFFECT UNTIL AUGUST 31, 2019 Lake Mission Viejo Junior Lifeguards
Medical Information

ALLERGIES
List all known. Do NOT leave blank. If no allergies please write- “no known allergies”
Please list allergy, reaction, and management of the reaction.