MARBLETOWN RECREATION DEPARTMENT
NINJA WARRIOR REGISTRATION FORM
CHILD’S NAME______BIRTHDATE______
ADDRESS______CITY/STATE______
HOME PHONE______WORK PHONE______CELL PHONE______
EMAIL ADDRESS______
EMERGENCY NAME AND NUMBER______
TEACHER’S NAME______
PRE-EXISTING MEDICAL CONDITIONS:______(allergies or chronic illnesses)
PHYSICIAN NAME______PHONE______
INSURANCE INFO.______MBER______
I understand that the Town of Marbletown’s Ninja Warrior insurance is secondary and mine is primary. There is a deductible for which I am responsible.
I hereby give my permission for my child to participate in Ninja Warrior. Further, I authorize emergency treatment of an injury or illness of my child if qualified medical personnel consider treatment necessary and perform the treatment. This authorization is granted only if I cannot be reached and a reasonable effort has been made to do so.
By the very nature of the activity, Ninja Warrior carries a risk of physical injury. No matter how careful the participant and coach are, no matter how many spotters are used, no matter what height is used or what landing surface exists, the risk cannot be eliminated. Reduced, yes but never eliminated. The risk of injury includes minor injuries such as bruises and more serious injuries such as broken bones, dislocations and muscle pulls. The risk also includes catastrophic injuries such as permanent paralysis or even death from landings or falls on the back, neck or head.
My child and I are aware that participating in gymnastics is a potentially hazardous activity. I assume all risks associated with participation in this sport, including but not limited to falls, contact with other participants, the effects of weather, traffic and risks to my child are known and understood by me.
The Youth Commission is not responsible for non-participants during Ninja Warrior class time. Please try to stay on the bleachers during class time for safety reasons. No one is allowed in hallways or other parts of the gym while classes are going on.
I hereby certify that I understand the Town of Marbletown’s and Rosendale’s Recreation rules and policy. I also understand that I may forfeit future admittance to programs if I do not adhere to these policies. I agree to follow all program rules and regulations. Furthermore, I agree to indemnify and hold harmless and defend the Towns of Marbletown and Rosendale, its officers, agents, servants and employees from any and all claims resulting from injuries, damages and losses sustained by me as a result of participation in this program and use of the Rondout Municipal Center.
I have read and understand this consent form and agree to its conditions on behalf of my child.
The following person/persons have my permission to pick up my child.
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______Date Signature of Parent/Guardian Print Name