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2. Release & Waiver of Liability & Assumption of Risk Agreement
   Please note, this is NOT a registration form. To register, please contact Parks & Rec at 805-688-7529. Payment can be accepted over the phone or in person at our office in Solvang at 411 Second Street.
4. Participant Information
6. Name*
7. Birthdate*
   Birthdate
8. Age*
10. Parent's or Guardian's Name
11. Email Address
13. Address*
14. City*
15. Zip*
17. Home Phone
18. Work Phone
19. Cell Phone
25. Emergency Contact Information
    (Other than Parent / Guardian)
27. Name
28. Phone Number
32. Immunization Records*

    Please note that immunization records are required for participation in the summer program.

    1. I have read and understand.
36. About the Participant
38. Does your child know how to swim?*

    1. Yes

    1. No
40. Is your child currently taking any medications the cities of Buellton or Solvang need to be aware of?

    1. Yes

    1. No
42. If yes, please list below.
44. Does your child have allergic reactions to anything the cities of Buellton or Solvang should be aware of? (i.e. medications, bee stings, food, etc.)

    1. Yes

    1. No
46. If yes, please list below.
48. Is there any additional information the Cities of Buellton or Solvang may need to be aware of?

    1. Yes

    1. No
50. If yes, please provide details below.
54. Participation Agreement*

    The undersigned parents/guardian of the participant, a minor, gives permission for the minor to participate in the Cities of Buellton and Solvang Parks and Recreation Program. The parents/guardian accepts full responsibility for delivering the participating child to the program at the appointed hour and for picking up the child at the conclusion of the program. The parents/guardian recognize that there is the possibility of accident and injury resulting from the child’s participation in the program.

    1. I have read and understand.
56. Medical Agreement*

    The Cities of Buellton or Solvang are authorized to employ or utilize any emergency medical facility and the registered physicians or surgeons licensed under the provisions of the medical staff of the facility to perform any necessary diagnosis or treatment deemed necessary. The undersigned understand that the undersigned are responsible for any and all charges incurred due to the treatment.

    1. I have read and understand.
58. Full Release of Liability*

    The undersigned have carefully read this release and hereby agree to hold the cities of Buellton and Solvang, their officers, agents and employees harmless from and against any and all causes of action, claims, liabilities, obligations, judgements or damages, including reasonable attorneys’ fees and costs of litigation arising from activities in the performance of the recreation program, or while traveling to, or returning from or outside the advertised hours of the cities of Buellton or Solvang’s parks and recreation programs, excepting only those actions, claims, liabilities, obligations, judgements or damages arising out of the sole negligence of the City of Buellton or the City of Solvang. The undersigned is/are aware that this is a full release of all liability and sign it of their own free will.

    1. I have read and understand.
60. Photo Release*

    I hereby grant the Cities of Buellton or Solvang, without expectation of compensation of any kind, the unrestricted right and permission to copyright and use, re-use, publish, and republish photographic portraits or pictures of me or in which I may be included intact or in part, composite or distorted in character or form, without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for illustration, art, promotion, advertising, trade, or any other purpose whatsoever. I hereby certify that I am the parent or guardian of the participant named above, and do hereby give my consent without reservation to the foregoing on behalf of this person.

    1. I have read and understand.
64. Participant's Agreement*

    I have read this document signed by my parent or guardian and join the waiver, release and assumption of risk. I am aware of the risks involved in my participation in recreation events or activities.

    1. The participant has read and understands.
68. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
70. Electronic Signature*
71. Relation to Child*

    1. Parent

    1. Guardian
73. Letter of Guardianship
    Please upload a signed copy of your letter of guardianship.
Leave This Blank:


75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit Submit and Print

* indicates a required field