Macomb Township Parks Recreation Form – Fill Out and Use This PDF

MACOMB TOWNSHIP PARKS & RECREATION

RECREATION CENTER DAILY WAIVER FORM

(Please print & fill out this form completely & legibly)

HEAD OF HOUSEHOLD ______________________________________ BIRTHDATE:______________ ฀ FEMALE ฀ MALE

Address ___________________________________________________________________________________________

City _______________________________________________ Zip ___________________ ฀ Resident ฀ Non-Resident

Phone: Home (____)___________________Cell (____)___________________ E-Mail ________________________

Emergency Contact Name: __________________________________________ Relationship ______________________

Phone: Home (____)___________________ Work (____)___________________ Cell/Pager (____)_________________

Medical Conditions or special needs we should be aware of __________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

MACOMB TOWNSHIP RELEASE AGREEMENT

In consideration of being permitted to participate in the township activity or use of any facilities in connection with this activity, the undersigned agrees to the following:

1.The undersigned hereby releases, waives, discharges and convenants not to sue Macomb Township, it’s employees, officers and agents (herein referred to as “releasees”) from all liability to the undersigned his or her personal representatives, assigns, heirs, and next of kin for any loss, damage, or claim therefore on account of injury to the person or property of the undersigned whether caused by any negligent act or omission of the releasees or otherwise while the undersigned is participating in the Township activity or using any facility in connection with the activity.

2.The undersigned hereby agrees to indemnify and hold harmless the releasees from all liability, claims, demands, causes of action, charges, expenses, and attorney fees (including attorney fees to establish the releasee’s right to indemnify or incurred on appeal) resulting from involvement in this activity whether caused by any negligent act or omission of the releasees or otherwise.

3.The undersigned hereby assumes full responsibility for and risk of bodily injury, death or property damage while upon Township property or participating in the activity or using any facilities and equipment whether caused by any negligent act or omission of releasees or otherwise.

The undersigned expressly agrees that the foregoing release and waiver, indemnity agreement and assumption of risk are intended to be as broad and inclusive as permitted by Michigan law and that if any portion thereof be held invalid, notwithstanding, the balance shall continue in full legal force and effect.

I acknowledge that I have read the foregoing and that I am aware of the legal consequences of this agreement, including that it prevents me from suing the Township or its employees, agents, or officers if I am injured or damaged for any reason as a result of participation in this activity. I further acknowledge that no oral representation; statements or inducements have been made.

If the participants are minors, his or her custodial parent or legal guardian must read and execute this agreement: I hereby warrant that I am the legal guardian or custodial parent of the above listed persons who are minors, and agree, on my own and on said minor’s behalf to the terms and conditions of the foregoing agreement.

Signature ______________________________________ Print Name ______________________________ Date _______

Staff Initials _____________