(Please print clearly. Form must be received prior to child being admitted to activities)


Date:-------------------------------


As the parent/legal guardian of--------------------------------------------------------age--------
I understand that said child will be participating in activities at the Escondido Humane Society and in the course of such activities said child may have direct contact with domestic, wild and farm animals.
I further understand that the behavior of domestic, wild and farm animals is sometimes unpredictable and that some domestic, wild and farm animals are capable of inflicting serious personal injury, as well as extensive property damage. Knowing the risks of handling domestic animals, on behalf of the minor and myself, I agree to assume those risks and to release, indemnify, and hold harmless the Escondido Humane Society and/or any of its officers, directors, employees, volunteers, agents or contractors for any and all personal injury and property damages resulting from said child�s participation in activities.
I also understand that said child is to remain on the Escondido Humane Society�s property for the duration of the activities. If the child leaves the property during participation with or without permission from a staff member, I release, indemnify, and hold harmless the Escondido Humane Society for any and all personal injury and property damages resulting from said child leaving the Escondido Humane Society�s property caused by said child.
I understand that my child may be sent home if said child is to become ill or behaves in a manner that is disruptive to camp and the Escondido Humane Society�s shelter activities.
I give the Escondido Humane Society authority to seek emergency medical treatment for said child. I know of no medical or other condition that would prevent said child from participation in activities at the Escondido Humane Society. In case of the need for medical treatment, Escondido Humane Society shall take reasonable efforts to notify me and get my participation and consent fro treatment. However, I realize that this may not be practical or that I may not be available. By submitting this form, I authorize the Escondido Humane Society, through its agents, employees and volunteers, on my behalf and at my account, to take such measures and arrange for such medical treatment as it may deem advisable for the health and well-being of my child, I authorize Escondido Humane Society to execute all documents necessary, including without limitation, medical releases, in order to secure such medical treatment.
I grant the right to photograph, reproduce, and use said child�s first name, picture, voice, words, silhouette, and other reproductions of physical likeness in connection with the Escondido Humane Society promotions.


Physician�s Name_________________________________________________

Physician�s Phone Number__________________________________________


Print the name and phone numbers of two emergency contacts_________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________


List name and phone number of other person(s) authorized to pick up your child____________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

Parent/Guardian Information:

Name___________________________________________________________________

Address__________________________________________________________________
Home Phone Number______________________________________________________

Work/Cell phone number_________________________________________________________________


Parent/Guardian Signature____________________________________________________


Return this completed form with your registration and payment to:

Escondido Humane Society
c/o Critter Connection Camp
3450 East Valley Parkway
Escondido, Ca. 92027

Waiver and Release of Liability