Release, Waiver, Indemnity Agreement & Representation
IN CONSIDERATION of being permitted to utilize the facilities and services, and to participate in the programs of the Silver Falls Family Young Men’s Christian Association (the YMCA), I, for myself and for each of my family members listed on the reverse side of this application, as well as for all heirs, successors in interest, and personal representatives, acknowledge, agree, and represent as follows:
That each of us has carefully inspected and evaluated each YMCA facility, service or program that we may use and have found the same to be safe and reasonably suited for the purpose of our use and participation;
That each of us hereby accepts full and exclusive responsibility for any and all injuries and damages that we may suffer as the direct or indirect result or consequence of our use of any of the facilities, equipment and services of the YMCA or our participation in the programs of the YMCA; and hereby releases, waives, discharges, covenants not to sue, or agrees to fully indemnify and save and hold harmless, the YMCA, its directors, officers, employees, and agents for injury or damage to us arising out of or in any way directly or indirectly relating to such use or participation including but not limited to our observation of any YMCA program or service;
That neither I, nor any person listed has ever been convicted of a sexual offense or registered as a sex offender in any jurisdiction; that I understand that the Silver Falls Family YMCA does not carry accident or health insurance and that I am participating in program activities at my own risk. That I have completely read, understood and voluntarily executed this document on the date set forth by my signature on the application.
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Signature Date:
Dated Received: ____________ Staff Initials: __________ ¨ Welcome Letter Sent
Receipted Amt.: ____________ Receipt No.: __________
Interest Notes: __________________________________________________________________________
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