The Hadley Hot Dog 5K

TOWN OF HADLEY, MA - PARK & RECREATION WAIVER Activity/Event: ___________________________________________ Date(s): ________________ Release of All Claims: Please read this form carefully and be aware that by signing this form you will be waiving and releasing claims for potential injuries, arising out of normal participation in voluntary extracurricular activities. The terms “I”, “me”, “my” also refer to parents or guardians as well as individual participants. In signing this form you are agreeing as follows: * I recognize and acknowledge that there are certain risks of physical injury, and I agree to assume the full risk of any injuries, which may be sustained as a result of normal participation in voluntary extracurricular activities. I further recognize and acknowledge that athletic activities involve strenuous exertion, potential body contact and risks of injury as a result of normal participation. * I agree to waive and relinquish any and all claims that I may have as a result of normal participation in voluntary extracurricular activities against the TOWN OF HADLEY, any and all other participating governmental units, any and all independent contractors, officers, agents and employees of the governmental bodies and independent contractors, and any and all other persons and entities, of whatever nature, that might be directly or indirectly liable for any injuries that I might sustain from normal participation in the activity (The parties described in the preceding sentence are referred to as “released parties” in the remainder of the Agreement). * I do hereby fully release and discharge the TOWN OF HADLEY and the other released parties from any and all claims for injuries, damage or loss which I may have or which may accrue on account of my/my child’s normal participation in voluntary extracurricular activities which do not arise out of or are not the direct result of negligent, grossly negligent, wanton, willful or intentional acts on the part of the above released parties. * In consideration of the time, training and facilities being made available, I understand and agree that any designated instructor, the Park & Recreation Department and Commissioners shall not be personally liable to me or my minor(s) for any claims, actions, suits or harm that may arise out of, or be in any way related to, my child’s. participation in any of the Park & Recreation Programs. * I understand the nature of the activities for which I am/my child is registering, and has read and fully understands this Waiver agreement. Emergency Medical Authorization: Yes No In the event that I/We cannot be reached in case of an emergency, I/We authorize any/all medical and/or surgical treatments, which are deemed advisable by emergency physicians and/or surgeons. I/We also recognize that the patient when admitted is to remain in the hospital care until his or her physician recommends patient’s discharge. Media Permission: Yes No Agrees to photos or video being taken which may be used for Park & Recreation Department use only in print or social media for marketing purposes only. Health Checklist: Yes No Today, or in the past 24 hours, no one in my household, including myself, has had any of the symptoms listed on the Health Checklist form (on reverse side). NOTE: If you answered YES to any of the daily health questions, you CANNOT participate in that day’s events/activities. Printed Name of Participant: _______________________________________________ Is Minor Child? Yes No Printed Name of Parent/Legal Guardian: ______________________________________ Emergency Phone:________________________________Email:____________________________________________ Signature of Parent/Legal Guardian: ___________________________________________ Date: _________________ SecureFee™ Registration Cancellation Insurance is offered in most states. If purchased, your registration may be covered for one of the covered reasons stated in the policy.