“Providing the youth of Santa Fe with a healthy lifestyle through recreational activities”
With the assistance of the Santa Fe Community Foundation 501C(3) organization, this Fore Kids scholarship application is used to determine the needs of an organization or individual who could benefit to receive a scholarship to use the City of Santa Fe’s Genoveva Chavez Community Center (GCCC) and Municipal Recreations Complex Golf Course (Marty Sanchez).
Organization/Individual: _____________________________ Date of Birth: __________
Address: ________________________________________________________________
Phone: _________________________Email:_______________________________________
Requested Program:
- Learn to Swim
- Youth Programs (Summer, Afterschool, Day Camps)
- Recreation Center Reduced Punch Pass/Membership
- Youth Athletics (Leagues & Camps)
Please provide a short explanation as to why your organization or individual would benefit to receive this scholarship. Please all provide which activities you/they would be interested in: i.e Golf, Swimming, Basketball etc.
Please check the following that apply and provide proof of the selected documentation.
[ ] - Social Security Supplemental Income
[ ] - Reduced of Free Lunch Program
[ ] - NM Medicaid (Centennial Care)
I, __________________________________ (insert fill name) swear or affirm to any penalties provided by law that this information is true and correct. I consent to any reasonable investigation and substantiations of the information.
Signature: ________________________________ Date: _________________________
Signature: ________________________________ Date: _________________________
MORE INFORMATION ON THE BACKSIDE
ASSUMPTION OF RISK, WAIVER, AND RELEASE FROM LIABILITY FORM
In consideration of the use of the property, facilities and/or services of City of Santa Fe Recreation Division or any Auxiliary organizations (Auxiliaries) participating or sponsoring recreational program, the undersigned agrees as follows:
- RISK FACTORS: The undersigned understands and acknowledges that the use of equipment, facilities and services provided by the Recreation Division (physical sports, weight and cardiovascular training, dance, aerobics, swimming, ice skating, golf, sports clubs and any other programs and services sponsored by the Recreation Division or its associated Auxiliaries) involves risks such as RISK OF PROPERTY DAMAGE, BODILY INJURY, AND POSSIBLE DEATH which might result from the use of equipment or facilities, from the activity itself, from the acts of others, or from the unavailability of emergency medical care.
- ASSUMPTION OF RISK: The undersigned ASSUMES ALL RISKS THAT ARISE OUT OF THE USE OF THE EQUIPMENT OR FACILITIES, THE ACTIVITY ITSELF, THE ACT OF OTHERS, OR THE UNAVAILABILITY OF EMERGENCY CARE, including but not limited to, those RISK FACTORS described in section 1 above.
Items 1-2: (Initials)
- RELEASE: The undersigned RELEASES the City of Santa Fe, the Auxiliaries, the officers, employees and agents of each (Released Parties) and agree NOT TO SUE the Released Parties for any claims, injuries, or damages, arising from the use of equipment or facilities, from the activity itself, from the acts of others, or from the unavailability of emergency medical care. The undersigned understands that this release includes those claims, injuries or damages based on death, bodily injury or property damage whether or not caused by the negligent acts, omissions or other fault of the Released Parties.
- INDEMNIFY, DEFEND AND HOLD HARMLESS: The undersigned agrees to INDEMNIFY AND DEFEND the Released Parties against, and hold them harmless from any or all claims, causes of action, damage judgments, costs or expenses, including attorney fees which in any way arise from the use of equipment or facilities, from the activity itself, from the acts of others, or from the unavailability of emergency medical care, including those based on death, bodily injury or property damage.
Items 3-4: (Initials)
- PAY: The undersigned agrees to pay for any or all damages to any property of the City of Santa Fe caused by the undersigned either negligently, willfully or otherwise.
- REPRESENTATIVES: The undersigned enters into this agreement for himself/herself, his/her heirs, assigns and legal representatives.
- EMERGENCY TREATMENT CONSENT: The undersigned, as a participant in the subject activity, hereby consents to medical treatment in a medical emergency where the undersigned is unable to consent to such treatment.
- INSURANCE: The undersigned understands that the City of Santa Fe and its Auxiliaries do not carry participant insurance. The undersigned is encouraged to have a physical examination and to purchase health insurance prior to any and all participation.
- PHOTOGRAPHS: The undersigned understands and grants the City of Santa Fe permission to take photographs of me and my family participating in recreational activities for the purpose of publicizing recreational programs and facilities.
Items 5-9: (Initials)
- ACKNOWLEDGMENT: The undersigned has read and understands this agreement and realizes it relates to surrendering valuable legal rights and does so freely and voluntarily.
Item 10: (Initials)
Signature: Date:
Staff Signature:
CONSENT AND RELEASE ON BEHALF OF PARTICIPANT
I am the parent and/or legal guardian of the above named minor. I have read and understand the agreement involves surrendering valuable legal rights of the minor and myself. I agree to be bound by all terms of this agreement. I also give my consent to the participation in the activity of the minor and for the minor to receive emergency medical treatment.
Date:
Signature of Parent/Legal Guardian – Consent and Release on behalf of the Minor
EMERGENCY CONTACT INFORMATION: (PRINT)
NAME
TELEPHONE NUMBER
For Staff Use Only:
Approved By: ______________________________________ Initials: ____________
Scholarship Use: ________________________________ Value: $_______________