Corvallis Juggling and Unicycling Club

One Wheel Wonders

Corvallis Juggling and Unicycling Club

Sponsored by Corvallis Parks and Recreation, Corvallis Cyclery and Wilson School

Program Agent: Angela Schwindt:

325 NW 10th St. Corvallis, OR 97330-6105. Ph: 541. 758.7246

Liability Release (required) Last Name (print):______

First Name(s): ______

______

Policies and Procedures:

·  Children under age 15 must be accompanied by an adult chaperone during club and activities. Supervision is responsibility of chaperone.

·  Participants and spectators will behave in a safe and respectful manner. (Do not take unnecessary risks or endanger the safety of others in the gym.)

·  Activities in the gym may include Unicycling, Juggling, Yo-Yo, Magic, balloons and other object manipulation. No skateboarding, tricycles, bicycles or any equipment deemed dangerous or in conflict to the participants will be allowed.

If riding a unicycle:

·  Helmets and sturdy (closed toe, rubber sole) shoes required.

·  You must receive basic “starting” directions from an adult instructor before attempting to ride (first unicycle lesson).

·  Participants must meet criteria receive permission from the facilitator to ride a giraffe unicycle or use related equipment during club or team practice times.

I hereby certify that I am 18 years of age or older and/or I am the parent or legal guardian of the participant who is under 18 years of age. I understand that any sports/recreation program has an inherent risk of being strenuous, or could result in death or injury to me or my child. I assume all risks as a result of participation in this program. If I cannot be reached in an emergency situation, I hereby give permission to the Facilitator of this club to arrange for transportation and/or emergency medical treatment if my child or I are seriously injured while participating in this program. For myself, my heirs and assigns I agree to waive, release and forever discharge any claim for injury or damage, and to hold harmless the City of Corvallis, its officers, agents and employees against any claim, loss, liability or expense, including attorney’s fees, resulting directly or indirectly from participation in this program.

SIGNATURE OF ALL PARTICIPANTS 18+ OR MINOR’S LEGAL GUARDIAN

x______Date ______

form revision 11/13