Hours of Operation Monday Thursday 5 to 8 p.m.

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1 The Jerry Ortiz Memorial Boxing & Youth Fitness Gym is dedicated to enriching the quality of life for children and at-risk youth in the San Gabriel Valley area by promoting physical activity and good sportsmanship in a safe environment. Boxing and fitness programs at the gym, as well as recreational activities, encourage and motivate young people to exercise and grow in their personal and physical development and provide the knowledge necessary to make healthy lifestyle choices. Under the guidance of a dedicated and caring staff, program participants benefit from lessons about self-esteem, self-confidence, teamwork and respect for others. The Jerry Ortiz Memorial Boxing & Youth Fitness Gym honors the memory of former El Monte resident Jerry Ortiz, a Los Angeles County Sheriff s deputy killed in the line of duty on June 24, Jerry Ortiz was an avid boxer, a brave man, a loving husband, a dedicated father and, above all else, a hero. Hours of Operation Monday Thursday 5 to 8 p.m. Programs (open to boys and girls) Check out for information on the following programs: Beginners Novices Boxing Team Running Team Age Requirements Boxing and Running Teams 8-17 years old Weightlifting years old Registration Fees Registration $60 (includes registration, first month dues, training uniform and USA Boxing license) Monthly Dues $10 Registration Requirements Physical Exam Signed Medical History Form (with full medical disclosure) Signed Liability Release Form Two Passport Photos Copy of Birth Certificate 1 of 5

2 Gym Application Please mark the applicable choice: Student Trainer Volunteer Name: Address: Last First Middle Street City Zip of Birth: / / Age Phone: Primary Alternate #1 Alternate #2 School: Name (if applicable) Grade Emergency Contact Name (Print) Phone Number Address Relationship Have you ever been contacted by a law enforcement agency? Yes or No (If yes, please explain): (All pages must be completed) 2 of 5

3 Gym Application Permission To Conduct a Background Investigation (for trainers and volunteers only) As an applicant for the Jerry Ortiz Memorial Boxing & Youth Fitness Gym, I hereby authorize the Jerry Ortiz Memorial Boxing & Youth Fitness Gym, through the El Monte Police Department, to conduct a criminal history background investigation which includes convictions, pending charges and outstanding warrants. I understand that all available police and criminal records will be checked and the information will be used to determine eligibility to participate with the Jerry Ortiz Memorial Boxing & Youth Fitness Gym. All information is to remain confidential as required by state and federal statutes. Signature of Volunteer/Trainer Signature of Parent or Guardian (if under 18 years old) Program: Youth Boxing and Fitness Program Position: Trainer Volunteer Front Office Coach 3 of 5

4 Liability Release Form (Please type or print) I, the undersigned, (Parent s residing at (Address), California, (Zip), do hereby give my permission for (Participant s to participate with the Jerry Ortiz Memorial Boxing & Youth Fitness Gym. I voluntarily and knowingly release and discharge the Jerry Ortiz Memorial Boxing & Youth Fitness Gym, agents, successors, assigns and all others who may be liable from all claims, present and future, known or unknown, in any manner arising out of (Participant s participation with the Jerry Ortiz Memorial Boxing & Youth Fitness Gym. I also acknowledge that (Participant s has no limited medical conditions and is fully capable of participating in the program. I appoint the Jerry Ortiz Memorial Boxing & Youth Fitness Gym to act in my place in the event that (Participant s should require medical attention while involved in the Jerry Ortiz Memorial Boxing & Youth Fitness Gym. This appointment is for the purpose of securing benefits for the health and welfare of (Participant s and expressly includes the authority to sign releases to physicians who may render emergency medical care and services. I promise to assume liability for payment of all such professional services and to reimburse the Jerry Ortiz Memorial Boxing & Youth Fitness Gym for any expenses that may be incurred for treatment, care, drugs and other services for (Participant s. In consideration of all above, as well as the supervision provided on my behalf and on behalf of (Participant s, I hereby agree to hold the Jerry Ortiz Memorial Boxing & Youth Fitness Gym, agents, successors, assigns and all others who may be liable, harmless for results of any decision it may take in connection with the care and treatment of (Participant s. I agree that if the above-mentioned participant s behavior is such that it endangers the welfare of the entire group, the Jerry Ortiz Memorial Boxing & Youth Fitness Gym has my permission to send him/her home. I agree that I am responsible for the transportation of (Participant s to and from functions. I agree that photographs may be taken of (Participant s with the Jerry Ortiz Memorial Boxing & Youth Fitness Gym. while he/she is involved Signature of Parent or Guardian Home Address Home Telephone City State Zip Alternate Phone Subscribed and sworn before me on (). For Office Use Only Representative from Jerry Ortiz Memorial Boxing & Youth Fitness Gym 4 of 5

5 Medical History Form (Please type or print) A written report of a physical examination performed by a qualified physician is required for an applicant to participate in the Jerry Ortiz Memorial Boxing & Youth Fitness Gym. The applicant shall also have current protection against diphtheria, tetanus, poliomyelitis, measles and rubella, or a statement from a physician that immunization is in progress. All immunization records must be attached to the medical history form along with a copy of a medical insurance card. Name of Applicant (please print) of Physical Physical Condition of Applicant: SATISFACTORY UNSATISFACTORY The following signature is required indicating that the applicant is capable of strenuous physical exercise: Physician (please print) Physician Signature Address Please list below any unusual physical condition(s) the Jerry Ortiz Memorial Boxing & Youth Fitness Gym should be aware of: I understand that first aid will be available for my child, that my child will be closely supervised and that hospital care will be given at the expense of the parent or guardian. I further understand that in case of serious illness or injury, I will be notified. If it is impossible to reach me in a timely manner, I hereby give my permission for emergency treatment or surgery recommended by the attending physician. Signature of Parent or Guardian Address Phone Number Alternate Number Medical Insurance Company Name Policy Number 5 of 5