Permission Slip

I, ___________________________, hereby grant permission for my child _______________________________ to participate with The Korean Youth Center of New York in THE FUSE 2013 RETREAT on Sunday, February 17 to Monday, February 18. To indicate your agreement, please check the following boxes: I have already submitted or will be submitting (before February 10, 2013) a 2013 Medical Release Form. In the event of an emergency, I give my permission for the leaders of this event to seek medical treatment for my child and authorize medical treatment including but not limited to emergency surgery or medical treatment, and assume responsibility for all medical bills, if any. My child agrees to obey all the rules and regulations established by the leaders of this activity. Should it be necessary for the participant to return home due to medical reasons, disciplinary action, or otherwise, I assume all transportation costs. I also agree to be fully liable for any injuries and damages caused by my child, and for any subsequent civil or criminal charges pressed against my childs causes. I, the undersigned (if the participant is 18 years of age or older) or parent / guardian of the above listed minor participant, acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the premises or of any of the equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not to sue THE KOREAN YOUTH CENTER OF NEW YORK, its affiliated organizations and sponsors, their coaches, managers, employees and associated personnel, officers, directors, agents, including the owners and leasers of the premises used to conduct the event, all of which are hereinafter referred to as releases, from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicants participation in the Programs and / or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize. I have read the above waiver / release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily. I understand that this document may not be altered in any manner and that any alteration without the express written consent of the KOREAN YOUTH CENTER OF NEW YORK will cause the participant to be removed from the program.

___________________________________________ Signature of Parent or Legal Guardian

(___/___/______) Date

Contact Information: Address: ___________________________________________________________________________________________ Contact Numbers: (Home) ___________________ (Work) ___________________ (Cell) ____________________ Emergency Contact (To be contacted if Primary Contact CANNOT be reached) Name of Emergency Contact: ____________________________ __ Relationship to Participant: __________________ Contact Numbers: (Home) ___________________ (Work) ___________________ (Cell) ____________________

2013 The Korean Youth Center of New York