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HomeMy WebLinkAboutSpooky_ Sports1_10_12.pdfBozeman Parks and Recreation Department PARTICIPANT INFORMATION, MEDICAL RELEASE, VEHICLE HOLD HIA,RMLE /SS� AGREEMENT Name IQ,� r Address Birth Date City, State Guardian 1 f liiS�i� -- C_1AY4 Current Date 0 a Home Phone Cell Phone i S q —S 1 ,)-I Work Phone Guardian 2 skl�lem- Home Phone Cell Phone -� Q e rk Phone Other Emergency Contact and Phon MEDICAL HISTORY Allergies Medications 01 Other Medical Information �J'b - X70 -0D l Preference Information (i.e. r61'ease_do not give soda,yegetarian, no processed snacks, etc.) MEDICAL RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to secure any emergency related hospital, medical, dental, or surgical care, treatment and /or procedures for the above named participant. Parent also consents in the event of injury to the participant, staff or volunteers can sign for participant to receive care, treatment and /or procedures under the instructions and directions of the licensed physicians on call at the emergency room of the nearest hospital or emergency facility. The staff /volunteers shall notify parent /guardian at the earliest possible time during or after care, treatment, and /or procedures. Parent knowingly and voluntarily consents in advance to such care, treatment, and /or procedures to encourage physicians and coaches and /or procedures. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from any and all costs arising out of such care, treatment, and /or procedures. VEHICLE USE RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to transport the above named participant in a vehicle owned and insured by the City of Bozeman and admits full knowledge of risk and dangers inherent in riding in this vehicle. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from all injuries, claims, demands, actions, suits, costs (Including attorney's fees), and liabilities of any character whatsoever involving or relating to any and all harm, injury or damage suffered by the above named participant arising out of the participant's presence in a vehicle owned by the City of Bozeman. icipant Signature / Date nature Parent or Guardian Signaturd / Date Bozeman Parks and Recreation Department Liability Release The undersigned, be' g at least 21 �s o age, hereby represents that he or she is the parent or guardian of _ here after referred to as the "participant." Further, the undersigned warrants and represents the participant is in good health and there are no special problems associated with the participant and the undersigned has left no special instructions regarding the participant which have not been listed on the registration form. I /we understand and accept the fact the City of Bozeman Recreational activities in its various forms is a HAZARDOUS sport which could have inherent dangers and risks. I /we realize injuries can occur and are a common and ordinary occurrence in activity participation. I /we agree, as a condition of being allowed to participate in Bozeman Parks and Recreation Department activities, I /we freely accept and voluntarily ASSUME ALL RISKS OF PERSONAL INJURY or property damage which results in any way from conditions on or about the premises and facilities, the operation of the facilities or in the course of travel to or from any such program, or activities in the area. I /we freely accept the full responsibility for any and all damage or injury of any kind which may result and agree to indemnify and hold harmless City of Bozeman, and their subsidiaries, their affiliates, and employees acting officially otherwise harmless for any claim, demand actions or causes of action arising out of or on account of any injury or damage to said participant or participant's property. The participant authorizes authorized personnel to call for medical care for the participant or to transport the participant to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed for the participant. The undersigned agrees upon transporting of the participant to any such medical facility or hospital that City of Bozeman shall not have any further responsibility for the participant. Further, the participant / guardian agrees to pay all costs associated with such medical care and related transportation for the participant and shall indemnify and hold harmless City of Bozeman and the activity / venue of and from any costs incurred therein, as provided in the preceding paragraph. This release shall be binding upon the assignees, surrogates, distributees, heirs, next of kin, executors, and administrators of the undersigned and may be pled by Bozeman Parks and Recreation Department and the activity/ program/ venue as a complete bar and defense against any claim, demand, action or cause of action by or on behalf of the undersigned. I /WE HAVE CAREFULLY READ AND UNDERSTOOD THE TERMS OF THIS RELEASE AGREEMENT. I /WE ARE SIGNING IT FREELY AND REALIZE IT IS BINDING UPON MYSELF, MY HEIRS, AND ASSIGNS, AND IN THE EVENT I AM SIGNING IT ON BEHALF OF MY MINOR, I HAVE FULL AUTHORITY TO DO SO, REALIZING ITS BINDING EFFECT ON THEM AS WELL AS MYSELF. Further, full permission is hereby given to use any photographs or movies of said participant taken during an activity or program for any purpose in promoting programs / activities / events of City of Bozeman. Participant Name V � I' ► Parent or Guardian Name, Parent or Guardian Signature Date THIS IS A RELEASE OF LIABILITY. PLEASE READ CAREFULLY BEFORE SIGNING OR ENGAGING IN THIS ACTIVITY / PROGRAM. t i Bozeman Parks and Recreation Department PARTICIPANT INFORMATION, MEDICAL RELEASE, VEHICLE HOLD HARMLESS AGREEMENT Name �1G Sl/► I�1� Address 130 04- , � ell U/W4ti, �l Birth Date City, State Guardian 1 �{r� 9. wv�, Current Date l dl n t I Z Home Phone Cell Phone SJ of 01 -� ] Work Phone ' l 13 � Guardid 2 Home Phone '' Cell Phone M 3x36 Work Phone (, X S-1 I Other Emergency Contact and Phone MEDICAL HISTORY Allergies Medications Other Medical Information Preference Information (i.e. please do not give soda, vegetarian, no processed snacks, etc.) MEDICAL RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to secure any emergency related hospital, medical, dental, or surgical care, treatment and /or procedures for the above named participant. Parent also consents in the event of injury to the participant, staff or volunteers can sign for participant to receive care, treatment and /or procedures under the instructions and directions of the licensed physicians on call at the emergency room of the nearest hospital or emergency facility. The staff /volunteers shall notify parent /guardian at the earliest possible time during or after care, treatment, and /or procedures. Parent knowingly and voluntarily consents in advance to such care, treatment, and /or procedures to encourage physicians and coaches and /or procedures. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from any and all costs arising out of such care, treatment, and /or procedures. VEHICLE USE RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to transport the above named participant in a vehicle owned and insured by the City of Bozeman and admits full knowledge of risk and dangers inherent in riding in this vehicle. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from all injuries, claims, demands, actions, suits, costs (Including attorney's fees), and liabilities of any character whatsoever involving or relating to any and all harm, injury or damage suffered by the above named participant arising out of the participant's presence in a vehicle owned by the City of Bozeman. Participant Signature / Date Signature Parent or Guardian Signature / Date Bozeman Parks and Recreation Department Liability Release The undersigned, being at least 21 years of age, hereby represents that he or she is the parent or guardian of -54 Z � (-, Sr, �� -�. ___ hereafter referred to as the "participant." Further, the undersigned warrants and represents the participant is in good health and there are no special problems associated with the participant and the undersigned has left no special instructions regarding the participant which have not been listed on the registration form. I /we understand and accept the fact the City of Bozeman Recreational activities in its various forms is a HAZARDOUS sport which could have inherent dangers and risks. I /we realize injuries can occur and are a common and ordinary occurrence in activity participation. I /we agree, as a condition of being allowed to participate in Bozeman Parks and Recreation Department activities, I /we freely accept and voluntarily ASSUME ALL RISKS OF PERSONAL INJURY or property damage which results in any way from conditions on or about the premises and facilities, the operation of the facilities or in the course of travel to or from any such program, or activities in the area. I /we freely accept the full responsibility for any and all damage or injury of any kind which may result and agree to indemnify and hold harmless City of Bozeman, and their subsidiaries, their affiliates, and employees acting officially otherwise harmless for any claim, demand actions or causes of action arising out of or on account of any injury or damage to said participant or participant's property. The participant authorizes authorized personnel to call for medical care for the participant or to transport the participant to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed for the participant. The undersigned agrees upon transporting of the participant to any such medical facility or hospital that City of Bozeman shall not have any further responsibility for the participant. Further, the participant / guardian agrees to pay all costs associated with such medical care and related transportation for the participant and shall indemnify and hold harmless City of Bozeman and the activity / venue of and from any costs incurred therein, as provided in the preceding paragraph. This release shall be binding upon the assignees, surrogates, distributees, heirs, next of kin, executors, and administrators of the undersigned and may be pled by Bozeman Parks and Recreation Department and the activity/ program/ venue as a complete bar and defense against any claim, demand, action or cause of action by or on behalf of the undersigned. I /WE HAVE CAREFULLY READ AND UNDERSTOOD THE TERMS OF THIS RELEASE AGREEMENT. I /WE ARE SIGNING IT FREELY AND REALIZE IT IS BINDING UPON MYSELF, MY HEIRS, AND ASSIGNS, AND IN THE EVENT I AM SIGNING IT ON BEHALF OF MY MINOR, I HAVE FULL AUTHORITY TO DO SO, REALIZING ITS BINDING EFFECT ON THEM AS WELL AS MYSELF. Further, full permission is hereby given to use any photographs or movies of said participant taken during an activity or program for any purpose in promoting programs / activities / events of City of Bozeman. / Sv-,, Participant Name Parent or Guardian Name, Parent or Guardian Signature Date l� THIS IS A RELEASE OF LIABILITY. PLEASE READ CAREFULLY BEFORE SIGNING OR ENGAGING IN THIS ACTIVITY / PROGRAM. ;W+ , l Bozeman Parks and Recreation Department PARTICIPANT INFORMATION, MEDICAL RELEASE, VEHICLE HOLD HARMLESS AGREEMENT Name ' UO.4 D �� ► S�d dress _ / 7�0 Birth Date �� City, State?' -� Tl 7 l- Guardian 1 o. l _ Current Date �C)//IO �- Home Phone '���� Cell Phone -'5 Work Phone Guardian 2 Home Phone L�Cell Phone Work Phone Ot�h(err Emergency Contact and Phoned _f__ MEDICAL HISTORY Allergies Wh Medications Other Medical'lnformation Preference Information (i.e. please do not give soda, vegetarian, no processed snacks, etc.) MEDICAL RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to secure any emergency related hospital, medical, dental, or surgical care, treatment and /or procedures for the above named participant. Parent also consents in the event of injury to the participant, staff or volunteers can sign for participant to receive care, treatment and /or procedures under the instructions and directions of the licensed physicians on call at the emergency room of the nearest hospital or emergency facility. The staff /volunteers shall notify parent /guardian at the earliest possible time during or after care, treatment, and /or procedures. Parent knowingly and voluntarily consents in advance to such care, treatment, and /or procedures to encourage physicians and coaches and /or procedures. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from any and all costs arising out of such care, treatment, and /or procedures. VEHICLE USE RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to transport the above named participant in a vehicle owned and insured by the City of Bozeman and admits full knowledge of risk and dangers inherent in riding in this vehicle. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from all injuries, claims, demands, actions, suits, costs (Including attorney's fees), and liabilities of any character whatsoever involving or relating to any and all harm, injury or damage suffered by the above named participant arising out of the participant's presence in a vehicle owned by the City of Bozeman. Participant Sign Lure / Date Signature Parent or Guardian Signature / D to The undersigned, bei guardian of the "participant." Bozeman Parks and Recreation Department Liability Release at least 21, years of age, hereby represents that he or she is the parent or , hereafter referred to as Further, the undersigned warrants and represents the participant is in good health and there are no special problems associated with the participant and the undersigned has left no special instructions regarding the participant which have not been listed on the registration form. I /we understand and accept the fact the City of Bozeman Recreational activities in its various forms is a HAZARDOUS sport which could have inherent dangers and risks. I /we realize injuries can occur and are a common and ordinary occurrence in activity participation. I /we agree, as a condition of being allowed to participate in Bozeman Parks and Recreation Department activities, I /we freely accept and voluntarily ASSUME ALL RISKS OF PERSONAL INJURY or property damage which results in any way from conditions on or about the premises and facilities, the operation of the facilities or in the course of travel to or from any such program, or activities in the area. I /we freely accept the full responsibility for any and all damage or injury of any kind which may result and agree to indemnify and hold harmless City of Bozeman, and their subsidiaries, their affiliates, and employees acting officially otherwise harmless for any claim, demand actions or causes of action arising out of or on account of any injury or damage to said participant or participant's property. The participant authorizes authorized personnel to call for medical care for the participant or to transport the participant to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed for the participant. The undersigned agrees upon transporting of the participant to any such medical facility or hospital that City of Bozeman shall not have any further responsibility for the participant. Further, the participant / guardian agrees to pay all costs associated with such medical care and related transportation for the participant and shall indemnify and hold harmless City of Bozeman and the activity / venue of and from any costs incurred therein, as provided in the preceding paragraph. This release shall be binding upon the assignees, surrogates, distributees, heirs, next of kin, executors, and administrators of the undersigned and may be pled by Bozeman Parks and Recreation Department and the activity/ program/ venue as a complete bar and defense against any claim, demand, action or cause of action by or on behalf of the undersigned. I /WE HAVE CAREFULLY READ AND UNDERSTOOD THE TERMS OF THIS RELEASE AGREEMENT. I /WE ARE SIGNING IT FREELY AND REALIZE IT IS BINDING UPON MYSELF, MY HEIRS, AND ASSIGNS, AND IN THE EVENT I AM SIGNING IT ON BEHALF OF MY MINOR, I HAVE FULL AUTHORITY TO DO SO, REALIZING ITS BINDING EFFECT ON THEM AS WELL AS MYSELF. Further, full permission is hereby given to use any photographs or movies of said participant taken during an activity or program for any purpose in promoting programs / activities / events of City of Bozeman. Participant Name Parent or Guardian Name, Date -- I V 1 & //' � _ - - --m f I 5�IL - - Parent or Guardian Signature THIS IS A RELEASE OF LIABILITY. PLEASE READ CAREFULLY BEFORE SIGNING OR ENGAGING IN THIS ACTIVITY / PROGRAM. t % Bozeman Parks and Recreation Department PA_fRLTICIP� ANT INFORMATION, MEDICAL RELEASE, VEHICLE H OLD HARMLESS A GREEMENTT ��{� -U y' �J/M �I Name e .%J Address Birth Date (2 -1 I / d 1! City, State 0 �F rn Guardian 1 ��� �'c �Ti j��-� (J Current Date 0 ��- ��D�Glo? ,r l Home Phone Cell Phone v/ �ork one / r7 Guardian 2 �� j� / ► I`"�� / Home Phone Cell Phone �✓ J Work Phone Other Emergency Contact and Phone MEDICAL HISTORY Allergies Medications Other Medical Information Preference Information (i.e. please do not give soda, vegetarian, no processed snacks, etc.) MEDICAL RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to secure any emergency related hospital, medical, dental, or surgical care, treatment and /or procedures for the above named participant. Parent also consents in the event of injury to the participant, staff or volunteers can sign for participant to receive care, treatment and /or procedures under the instructions and directions of the licensed physicians on call at the emergency room of the nearest hospital or emergency facility. The staff /volunteers shall notify parent /guardian at the earliest possible time during or after care, treatment, and /or procedures. Parent knowingly and voluntarily consents in advance to such care, treatment, and /or procedures to encourage physicians and coaches and /or procedures. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from any and all costs arising out of such care, treatment, and /or procedures. J VEHICLE USE RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to transport the above named participant in a vehicle owned and insured by the City of Bozeman and admits full knowledge of risk and dangers inherent in riding in this vehicle. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from all injuries, claims, demands, actions, suits, costs (Including attorney's fees), and liabilities of any character whatsoever involving or relating to any and all harm, injury or damage suffered by the above named participant arising out of the participant's presence in a vehicle owned by the City of Bozeman. Particip t Signature / Date Signature Parent or Guardian Signature / Date Bozeman Parks and Recreation Department Liability Release The undersigned, being al least 21 years of age, hereby represents that he or she is the parent or guardian of vt N j 4�1_ ���t�i> hereafter referred to as the "participant." Further, the undersigned warrants and represents the participant is in good health and there are no special problems associated with the participant and the undersigned has left no special instructions regarding the participant which have not been listed on the registration form. I /we understand and accept the fact the City of Bozeman Recreational activities in its various forms is a HAZARDOUS sport which could have inherent dangers and risks. I /we realize injuries can occur and are a common and ordinary occurrence in activity participation. I /we agree, as a condition of being allowed to participate in Bozeman Parks and Recreation Department activities, I /we freely accept and voluntarily ASSUME ALL RISKS OF PERSONAL INJURY or property damage which results in any way from conditions on or about the premises and facilities, the operation of the facilities or in the course of travel to or from any such program, or activities in the area. I /we freely accept the full responsibility for any and all damage or injury of any kind which may result and agree to indemnify and hold harmless City of Bozeman, and their subsidiaries, their affiliates, and employees acting officially otherwise harmless for any claim, demand actions or causes of action arising out of or on account of any injury or damage to said participant or participant's property. The participant authorizes authorized personnel to call for medical care for the participant or to transport the participant to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed for the participant. The undersigned agrees upon transporting of the participant to any such medical facility or hospital that City of Bozeman shall not have any further responsibility for the participant. Further, the participant / guardian agrees to pay all costs associated with such medical care and related transportation for the participant and shall indemnify and hold harmless City of Bozeman and the activity / venue of and from any costs incurred therein, as provided in the preceding paragraph. This release shall be binding upon the assignees, surrogates, distributees, heirs, next of kin, executors, and administrators of the undersigned and may be pled by Bozeman Parks and Recreation Department and the activity/ program/ venue as a complete bar and defense against any claim, demand, action or cause of action by or on behalf of the undersigned. I /WE HAVE CAREFULLY READ AND UNDERSTOOD THE TERMS OF THIS RELEASE AGREEMENT. I /WE ARE SIGNING IT FREELY AND REALIZE IT IS BINDING UPON MYSELF, MY HEIRS, AND ASSIGNS, AND IN THE EVENT I AM SIGNING IT ON BEHALF OF MY MINOR, I HAVE FULL AUTHORITY TO DO SO, REALIZING ITS BINDING EFFECT ON THEM AS WELL AS MYSELF. Further, full permission is hereby given to use any photographs or movies of said participant taken during an activity or program for any purpose in promoting programs / activities / events of City of Bozeman. Participant Name Parent or Guardian Name, ` Parent or Guardian Signature Date THIS IS A RELEASE OF LIABILITY. PLEASE READ CAREFULLY BEFORE SIGNING OR ENGAGING IN THIS ACTIVITY / PROGRAM. h Bozeman Parks and Recreation Department PARTICIPANT INFORMATION,, MEDICAL RELEASE, VEHICLE HOLD HARMLESS AGREEMENT Name �� Al (_ %�' 1' i F���J�c� Address 1� I [�_Ul5)qty\ OF- / 7 �� (� P 0 2� M lit 01 Birth Date _ � c� City, State 1 Guardian 1 L_& N o!' c"� f -` Current Date 0 Home Phone _ Cell Phone / ^' / �'OVdrk Phone 1 Guardian 2 Home Phone Cell Phori a �' Work Phone Other Emergency Contact and Phone MEDICAL HISTORY Allergies Medications 14/ Other Medical Information Preference Information (i.e. please do not give soda, vegetarian, no processed snacks, etc.) MEDICAL RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to secure any emergency related hospital, medical, dental, or surgical care, treatment and /or procedures for the above named participant. Parent also consents in the event of injury to the participant, staff or volunteers can sign for participant to receive care, treatment and /or procedures under the instructions and directions of the licensed physicians on call at the emergency room of the nearest hospital or emergency facility. The staff /volunteers shall notify parent /guardian at the earliest possible time during or after care, treatment, and /or procedures. Parent knowingly and voluntarily consents in advance to such care, treatment, and /or procedures to encourage physicians and coaches and /or procedures. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from any and all costs arising out of such care, treatment, and /or procedures. VEHICLE USE RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to transport the above named participant in a vehicle owned and insured by the City of Bozeman and admits full knowledge of risk and dangers inherent in riding in this vehicle. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from all injuries, claims, demands, actions, suits, costs (Including attorney's fees), and liabilities of any character whatsoever involving or relating to any and all harm, injury or damage suffered by the above named participant arising out of the participant's presence in a vehicle owned by the City of Bozeman. Participant Signature / Date Signature Parent or Guardia /0 Z" gnature / Date Bozeman Parks and Recreation Department Liability Release The undersigned, being at least 21 years of age, hereby represents that he or she is the parent or guardian of / 1/i .1' (; ;,4-) l hereafter referred to as the "participant." Further, the undersigned warrants and represents the participant is in good health and there are no special problems associated with the participant and the undersigned has left no special instructions regarding the participant which have not been listed on the registration form. I /we understand and accept the fact the City of Bozeman Recreational activities in its various forms is a HAZARDOUS sport which could have inherent dangers and risks. I /we realize injuries can occur and are a common and ordinary occurrence in activity participation. I /we agree, as a condition of being allowed to participate in Bozeman Parks and Recreation Department activities, I /we freely accept and voluntarily ASSUME ALL RISKS OF PERSONAL INJURY or property damage which results in any way from conditions on or about the premises and facilities, the operation of the facilities or in the course of travel to or from any such program, or activities in the area. I /we freely accept the full responsibility for any and all damage or injury of any kind which may result and agree to indemnify and hold harmless City of Bozeman, and their subsidiaries, their affiliates, and employees acting officially otherwise harmless for any claim, demand actions or causes of action arising out of or on account of any injury or damage to said participant or participant's property. The participant authorizes authorized personnel to call for medical care for the participant or to transport the participant to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed for the participant. The undersigned agrees upon transporting of the participant to any such medical facility or hospital that City of Bozeman shall not have any further responsibility for the participant. Further, the participant / guardian agrees to pay all costs associated with such medical care and related transportation for the participant and shall indemnify and hold harmless City of Bozeman and the activity / venue of and from any costs incurred therein, as provided in the preceding paragraph. This release shall be binding upon the assignees, surrogates, distributees, heirs, next of kin, executors, and administrators of the undersigned and may be pled by Bozeman Parks and Recreation Department and the activity/ program/ venue as a complete bar and defense against any claim, demand, action or cause of action by or on behalf of the undersigned. I /WE HAVE CAREFULLY READ AND UNDERSTOOD THE TERMS OF THIS RELEASE AGREEMENT. I /WE ARE SIGNING IT FREELY AND REALIZE IT IS BINDING UPON MYSELF, MY HEIRS, AND ASSIGNS, AND IN THE EVENT I AM SIGNING IT ON BEHALF OF MY MINOR, I HAVE FULL AUTHORITY TO DO SO, REALIZING ITS BINDING EFFECT ON THEM AS WELL AS MYSELF. Further, full permission is hereby given to use any photographs or movies of said participant taken during an activity or program for any purpose in promoting programs / activities / events of City of Bozeman. c y ki Participant Name Parent or Guardian Name, Pareni or Guardian Signature Date THIS IS A RELEASE OF LIABILITY. PLEASE READ CAREFULLY BEFORE SIGNING OR ENGAGING IN THIS ACTIVITY / PROGRAM. • �'f ff44.at N�a Ya \ \i Bozeman Parks and Recreation Department PARTICIPANT INFORMATION, MEDICAL RELEASE, VEHICLE HOLD HARMLESS AGREEMENT .� Name �� GL� V V ``�U✓� Address _ ( Birth Date �� "7-D l 'TJ City, State Guardian 1 LAV lJL ` V� \, CA \ Current Date Co I �� Home Phone Cell Phone ( lU;ork Phone Guardian 2 Q)\Uo%WA \ N) SSc V 1 Home Phone CellPhoneS '10 V 4 R0 Work Phone Other Emergency Contact and Phone MEDICAL HISTO Y Allergies Medications AA \\ 1 Iv Other Medical Information Preference Information (i.e. lease do not give soda, j egetarian no processed snacks, tc.) MEDICAL RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to secure any emergency related hospital, medical, dental, or surgical care, treatment and /or procedures for the above named participant. Parent also consents in the event of injury to the participant, staff or volunteers can sign for participant to receive care, treatment and /or procedures under the instructions and directions of the licensed physicians on call at the emergency room of the nearest hospital or emergency facility. The staff /volunteers shall notify parent /guardian at the earliest possible time during or after care, treatment, and /or procedures. Parent knowingly and voluntarily consents in advance to such care, treatment, and /or procedures to encourage physicians and coaches and /or procedures. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from any and all costs arising out of such care, treatment, and /or procedures. 1014, tla l'a � aaaa Bozeman Parks and Recreation Department PARTICIPANT INFORMATION, MEDICAL RELEASE, VEHICLE HOLD HARMLESS AGREEMENT � Name � e�( %(A W� Q5` Address �n s Prot2 SS,t(��� !� � Birth Date a ' ba City, State Guardian 1 l�PJ�1(�1.Jr0. y.�i e Current Date T' Home Phone 5451 1P Cell Phone( 40A)(Pg1i- o4(6 Work Phone Gud Home Phone Cell Phone Other Emergency Contact and Phone 1 VAp f i a&w 7o5\(" �i r 5I0- 4ao 5 5lo - L40 MEDICAL HISTORY Allergies �Ab Medications N i1 Other Medical Information y1 e 66"f- Isk - Work Phone Preference Information (i.e. please do not givl soda, vegetarian, no processed snacks, etc.) MEDICAL RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to secure any emergency related hospital, medical, dental, or surgical care, treatment and /or procedures for the above named participant. Parent also consents in the event of injury to the participant, staff or volunteers can sign for participant to receive care, treatment and /or procedures under the instructions and directions of the licensed physicians on call at the emergency room of the nearest hospital or emergency facility. The staff /volunteers shall notify parent /guardian at the earliest possible time during or after care, treatment, and /or procedures. Parent knowingly and voluntarily consents in advance to such care, treatment, and /or procedures to encourage physicians and coaches and /or procedures. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from any and all costs arising out of such care, treatment, and /or procedures. VEHICLE USE RELEASE Parent hereby authorizes the Bozeman Parks and Recreation Department and / or their named staff, and official volunteers to transport the above named participant in a vehicle owned and insured by the City of Bozeman and admits full knowledge of risk and dangers inherent in riding in this vehicle. Parent specifically indemnifies and holds harmless the Bozeman Parks and Recreation Department, staff and volunteers from all injuries, claims, demands, actions, suits, costs (Including attorney's fees), and liabilities of any character whatsoever involving or relating to any and all harm, injury or damage suffered by the above named participant arising out of the participant's presence in a vehicle owned by the City of Bozeman. Participant Signature / Date 0 aturb Parent or Guardian Signature / Date Bozeman Parks and Recreation Department Liability Release The undersigned, being at least 21 years of age, hereby represents that he or she is the parent or guardian of Q i i`,hA-, � n 4- hereafter referred to as the "participant." Further, the undersigned warrants and represents the participant is in good health and there are no special problems associated with the participant and the undersigned has left no special instructions regarding the participant which have not been listed on the registration form. I /we understand and accept the fact the City of Bozeman Recreational activities in its various forms is a HAZARDOUS sport which could have inherent dangers and risks. I /we realize injuries can occur and are a common and ordinary occurrence in activity participation. I /we agree, as a condition of being allowed to participate in Bozeman Parks and Recreation Department activities, I /we freely accept and voluntarily ASSUME ALL RISKS OF PERSONAL INJURY or property damage which results in any way from conditions on or about the premises and facilities, the operation of the facilities or in the course of travel to or from any such program, or activities in the area. I /we freely accept the full responsibility for any and all damage or injury of any kind which may result and agree to indemnify and hold harmless City of Bozeman, and their subsidiaries, their affiliates, and employees acting officially otherwise harmless for any claim, demand actions or causes of action arising out of or on account of any injury or damage to said participant or participant's property. The participant authorizes authorized personnel to call for medical care for the participant or to transport the participant to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed for the participant. The undersigned agrees upon transporting of the participant to any such medical facility or hospital that City of Bozeman shall not have any further responsibility for the participant. Further, the participant / guardian agrees to pay all costs associated with such medical care and related transportation for the participant and shall indemnify and hold harmless City of Bozeman and the activity / venue of and from any costs incurred therein, as provided in the preceding paragraph. This release shall be binding upon the assignees, surrogates, distributees, heirs, next of kin, executors, and administrators of the undersigned and may be pled by Bozeman Parks and Recreation Department and the activity/ program/ venue as a complete bar and defense against any claim, demand, action or cause of action by or on behalf of the undersigned. I /WE HAVE CAREFULLY READ AND UNDERSTOOD THE TERMS OF THIS RELEASE AGREEMENT. I /WE ARE SIGNING IT FREELY AND REALIZE IT IS BINDING UPON MYSELF, MY HEIRS, AND ASSIGNS, AND IN THE EVENT I AM SIGNING IT ON BEHALF OF MY MINOR, I HAVE FULL AUTHORITY TO DO SO, REALIZING ITS BINDING EFFECT ON THEM AS WELL AS MYSELF. Further, full permission is hereby given to use any photographs or movies of said participant taken during an activity or program for any purpose in promoting programs / activities / events of City of Bozeman. Participant Name Parent or Guardian Name, Parent or Guardian Signature Date 10 ' -7 ' THIS IS A RELEASE OF LIABILITY. PLEASE READ CAREFULLY BEFORE SIGNING OR ENGAGING IN THIS ACTIVITY / PROGRAM.