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Recreation and Culture Department
38260 10th Street East
Palmdale, CA 93550
661/267-5611
parksrec@cityofpalmdale.org

Open Monday-Thursday
7:30 am-6 pm
Closed Friday

After-School Fun Center General Release Form

Program Dates: August 8, 2016 through June 7, 2017

Afterschool Fun Center is offered only when school is in session. It is not offered on holidays, staff development days or during intersession breaks.

Students must be registered with payment prior to participation. A $5 late fee/day/child will be charged to your account if the fee is not paid on or before Monday of the current session by 12 pm.

A weekly rate is charged. You may register by using the following options:

  • Register and pay online at www.cityofpalmdale.org/playpalmdale. A current e-mail address must be provided to register online.
  • Register at the recreation and culture office, 38260 10th Street East.
  • Register and pay with credit card by calling the recreation and culture office at 661/267-5611.
  • A discounted fee is available for online and in-person office registrations. All phone registrations pay full course fee.
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RELEASE, WAIVER, AND ASSUMPTION OF RISK

I, the undersigned, am fully aware and understand the potential risk involved with my, or my child's participation in this physical activity. Dangers could include, but are not limited to cuts, bruises, broken bones and other debilitating or permanent physical and emotional injury, damage to personal property, or death.

I acknowledge that I voluntarily participate, or allow my child to participate, in this program. I hereby agree to assume all risk of injury, damage to persons and property, or death, and to hold the City of Palmdale, its officers, agents, volunteers or employees harmless from any liability for any injuries, or claim for damage, damage to goods, or death that may arise in connection with participation in this program. This Release, Waiver and Assumption of Risk also pertains to any actions of negligence by the City of Palmdale, its officers, agents, volunteers, or employees (excepting only the sole negligence or willful misconduct of the City) which may have caused or contributed to the injury, damage, or death. This Release, Waiver, and Assumption of Risk shall be binding upon my heirs and dependents as well as myself. I allow my child to participate freely and voluntarily in this activity and expressly assume all the risk of this program.

I hereby give permission to the City of Palmdale Recreation and Culture Department to use my or my child's photographs as they see fit in their seasonal recreational brochure. I understand the photographs belong to the City and I will not receive payment of any kind. In the event of illness or injury, the Palmdale Recreation and Culture Department is authorized to seek medical treatment and care for the above-named participant.

I understand that my child will not be under any supervision walking to and from the site. Also, children who arrive early will not be under any supervision until they are signed in. Children staying late will be supervised, however, a late fee will be charged. Once the program concludes for the day parents are given a 5 minute grace period to pick up their child. After the 5 minutes grace period there is a $1.00 per child charge for every 1 minute following. A $5 late registration fee will be charged to your account if student is not paid on or before the Monday of the current session by 12 pm. This $5 late fee is per day per child. Late fees will be added to your account at www.cityofpalmdale.org.

In the absence of a signature, fees paid and participation in the program and all its related activities shall constitute acceptance of the conditions set forth in this release.

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38300 Sierra Highway, Palmdale, CA 93550 · 661/267-5100 · 661/267-5122 - fax

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