THE UNDERSIGNED XXXXXX ASSUMES. FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH, OR PROPERTY DAMAGE due to negligence, action or inaction of the Releasees or otherwise while in, about, and/or while using any facilities or equipment thereon or participating in any program affiliated with US Pole Sports Federation. INITIAL
THE UNDERSIGNED XXXXXX ASSUMES. FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH, OR PROPERTY DAMAGE while in, about, or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon, or participation in any program affiliated with the YMCA. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Virginia and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ, UNDERSTANDS, AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements, or inducements apart from the foregoing written agreement have been made. DATE PARTICIPANT’S SIGNATURE DATE PARTICIPANT’S SIGNATURE DATE PARENT/GUARDIAN SIGNATURE (IF PARTICIPANT IS UNDER 18) DATE STAFF WITNESS SIGNATURE PLEASE PRINT: First Name: ________________________________________________ Middle Name: _________________________ Last Name: ____________________________________________ Date of Birth: ______________________________________________ Address: _____________________________________________________________________________________________ City: __________________________________________________________ State: _________ Zip: ___________________ Home Phone: ( ) E-mail: ______________________________________________________________________________________________________________________________________________________ Emergency Contact Information Name: _____________________________________________________________________________________________________ Phone: ( ) Please Check One: Staff Initials _______________ 🞏 Guest of Member 🞏 Trial Pass 🞏 Greater Richmond Member 🞏 South Hampton Roads Member 🞏 Away (list home branch here) ______________________________________________________________ Facility Pass: 🞏 Adult $10.00 (daily) 🞏 Family $20.00 (daily)
THE UNDERSIGNED XXXXXX ASSUMES. FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH, OR PROPERTY DAMAGE due to negligence of releasees or otherwise while in, about, or upon the premises of the Camp and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the Camp. THE UNDERSIGNED further expressly agrees that the forgoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Alabama and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITYAGREEMENT, and further agrees that no oral representations, statements, or inducement apart from the foregoing written agreement have been made. I HAVE READ THIS RELEASE I HAVE READ THIS RELEASE / / / / date participant’s signature date parent’s or guardian’s signature
THE UNDERSIGNED XXXXXX ASSUMES. FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of release or otherwise while in about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of New Jersey and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. MEMBER AND PARTICIPANT PROTECTION POLICY We take very seriously the safety and well-being of our members and participants and, to that end, have established policies and procedures that protect people utilizing our programs and facilities. The YMCA reserves the right to deny access or membership to any person. This includes but is not limited to, any person known to have been accused or convicted of any crime involving child abuse, sexual abuse or is a registered sex offender. By signing this form you certify that neither you nor anyone listed has been accused or convicted of a criminal offense listed above.
