Name (required)
Age (required)
Phone Number (required)
Email (required)
Emergency Contact #1 Name (required)
Emergency Contact #1 Phone Number (required)
Emergency Contact #2 Name (required)
Emergency Contact #2 Phone Number (required)
Hospital Preference (required)
Physician's Name
Physician's Phone Number
Insurance Policy Company
Policy Number
If you selected yes, please list medications you are allergic to?
If you selected yes, please list foods you are allergic to?
Please let us know of any physical and/or emotional issues in order to provide appropriate accommodations for you. (required)
In the event that I become ill or injured and I am not available to take action necessary for the wellbeing of myself, I hearby authorize Pueblo of Santa Ana personnel to take action necessary for the safety and wellbeing of myself, including securing medical treatment (at my expense). Please Initial on the below. (required)
I hereby release the Pueblo of Santa Ana and its respective offices, directors, employees, and agents from and against all claims, damages, liabilities, alleged or actual, which may occur in the normal participation of outdoor programs with the Santa Ana Pueblo Community Library. Please initial on the line below. (required)
I hereby give permission to utilize images captured during planned activities. This includes pictures by video, photo and digital camera. These photos will be used for the purposes of the Tamaya outdoor programming and Santa Ana Department of Education materials, publications, and social media, and I waive my rights of compensation or ownership thereto. Even if I do not approve photos to be utilized, they may be taken. Please initial on the line below. (required)
In the event that I become ill or not feeling well, I understand that I must refrain from activities and will provide notice to Library staff. Masks are not required but optional. Please initial on the line below. (required)
I have read and understand the policies and procedures of the Tamaya Peak and Pedal outdoor program/Santa Ana Pueblo Community Library as outlined above. Please initial on the line below. (required)
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