Hold Harmless And

HOLD HARMLESS AND

MEDICAL RELEASE FORM

<insert your YMCA’s name>

YMCA SKATE PARK

ADMISSION REQUIREMENTS AND PARK RULES

1. All skaters must have a valid photo I.D. to enter the park.

2. Hold Harmless forms must be signed in the presence of the Skate Park attendant.

3. Minors need to have their parent sign the Hold Harmless form in the presence of the Skate Park attendant or must have the signature notarized.

4. All participants must wear a helmet, wrist protectors, kneepads, and elbow pads at all times they are skating or are in the skating area.

5. Skating is restricted to the Skate Park only! Skating outside of the park will result in suspension of Skate Park privileges.

6. Skaters not obeying the direction and/or instruction of the Skate Park attendant will lose Skate Park privileges.

THERE ARE NO EXCEPTIONS TO THESE RULES!!!

SKATER INFORMATION:

Name (print) ___________________________________________

Local address ___________________________________________

City _____________________________ zip _________

Phone (home) __________________ (work) __________________

Birthdate ___________________________ age ___________

EMERGENCY INFORMATION:

Name (print) ___________________________________________

Relationship ___________________________________________

Phone (home) __________________ (work) __________________

HH2004/9
HOLD HARMLESS FORM

This release limits your right to recover damages in case of an accident.

READ BEFORE SIGNING

In applying to enter the YMCA SKATE PARK, I promise to inspect the park site and assure myself that the area and conditions are safe for skating purposes. I will further read and comply with all YMCA rules and regulations, note existing weather conditions, and voluntarily agree to assume all risks arising from conditions related to use of the skate site by my self and others. In consideration of your acceptance of my entry, I, intending to be legally bound, hereby, for myself, my heirs, executors and administrators, hold harmless and release and forever discharge the <insert your YMCA’s name>, their members, agents, and any other officials whatsoever arising from my presence or participation in the Skate Park. I attest that I am physically fit and have sufficiently trained for this activity and do hereby grant the sponsors such release as described herein. I also waive and release my photograph or likeness for any reason or purpose. I acknowledge that I have read and understand all of the above.

_______________________________________________ __________

SKATE PARK USER’S SIGNATURE DATE

NOTE: If under 18 years old, parent must sign below in the presence of the Skate Park attendant, or must have that signature notarized.

SKATE PARK USER’S PARENT’S SIGNATURE

I hereby certify that I am the parent or guardian of the skater named above, and do give my consent without reservation to the foregoing and agree to hold harmless the aforementioned from any liability.

_______________________________________________ __________

PARENT OR GUARDIAN’S SIGNATURE DATE

In the event that I cannot be reached in an emergency, I hereby give permission to any licensed physician, surgeon, clinic, or hospital to secure proper treatment and to order injection or anesthesia for my child as named above. I hereby state that my child is free from all communicable diseases, has not been treated for any such disease within the past six months, and has received all required immunizations.

______________________________________________ __________

PARENT OR GUARDIAN’S SIGNATURE DATE

NOTE: Hold Harmless and Medical Release form MUST be

signed to skate.