Oakland Park
Baseball Liability Waiver and Personal Responsibility Form
1. LIABILITY
INSURANCE INFORMATION
Insured (Your Name) _____________________________________________________________
Health Insurance
Company Name_____________________________________________________
Health Insurance
Company Phone # (______)__________________________________
Policy # _______________________________________________________________________
2. EMERGENCY
CONTACT
Their
Name_______________________________________________________________
Their Relationship to
You____________________________________________________
Their Home #: (_______)________________________________
Their Work #: (_______)_________________________________
Their Cell # (_______)___________________________________
ACCESSIBILITY: The City of Oakland,
Office of Parks and Recreation (OPR) is fully committed to compliance with
provisions of the Americans with Disabilities Act. Please direct all inquiries
concerning program and disability accommodations to the OPR Inclusive
Recreation Coordinator at (510) 615-5755 or [email protected]. TDD callers
please dial (510) 615-5883.
TITLE VI
COMPLIANCE AGAINST DISCRIMINATION 43CFR 17.6 (b): Federal and City of
Oakland regulations strictly prohibit discrimination on the basis of race,
color, national origin, age, handicap, gender, sexual orientation, AIDS or ARC.
RELEASE WAIVER
I hereby release and
hold harmless the City of Oakland and the Office of Parks and Recreation, its
directors, officers, employees, agents and all other persons acting on its
behalf, from any and all causes of action, liability, damage, loss, and
expense, including attorney fees and court costs, whether based upon causes of
action for strict liability, negligence, gross or otherwise, in connection with
the participation of me or my child in any activity conducted by the Office of
Parks and Recreation, whether on its premises or elsewhere. This release is
made in all my legal capacities, including on my own behalf, and on the behalf
of my spouse and any other parent or guardian of the reservation, and as legal
representative and guardian of the reservation
AUTHORIZATION FOR
MEDICAL TREATMENT
I hereby consent and
authorize the City of Oakland and the Office of Parks and Recreation staff to
obtain emergency medical care for myself or my child for any injury that may
result from participation in the activities and facilities of the Office of
Parks and Recreation or on or about its premises. I understand that the City of
Oakland, the Office of Parks and Recreation do not provide medical coverage for
participants of programs or at reserved facilities.
I
accept full financial responsibility for any property damage I cause with a
batted or thrown ball. If I hit or throw a ball that damages a car, window, or
house, I will confront the owner of the property, admit my personal
responsibility, and offer to accept financial responsibility for fixing the
damage.
Sign Name______________________________________________________
Print
Name_____________________________________________________
Drivers License # / Expiration
Date__________________________________
DATE
_________________________________________________________
[office use only] DATE RECEIVED and ENTERED _____________________________