January 20
City of Winter Haven
Parks, Recreation & Culture Department
Registration Form
Participant’s Name: ______D.O.B____/____/____
Last Name First Name M.I.
Address: ______Gender ______
Street Address City Zip
Phone Number: ______Grade ______School ______
Parent/Guardian Name: ______Work Phone Number______
E-Mail Address: ______Alternate Phone Number ______
Emergency Contact (other than parent/guardian): ______
Name Relationship
Phone Number: ______
Known Medical Conditions (Allergies or physical limitations):______
City of Winter Haven
Waiver and Release of Liability and Photo Consent
WAIVER: PLEASE READ CAREFULLY BEFORE SIGNING.
In consideration for Participant’s participation and registration in a City of Winter Haven Program, I (we), ______(Participant’s name or Participant’s parent(s) name(s) if Participant is a minor)(“releasor(s)”) hereby release, waive, discharge and covenant not to sue the City of Winter Haven, its elected officials, officers, employees, agents, participants, sanctioning organizations or any subdivisions thereof, field operators, sports officials, owners and lessees of premises used to conduct programs, eventsand/or practices (“releasees”) from all liability and from any and all loss or damage, and any claim or demands therefore, on account of injury to the named Participant above, whether caused by the negligence of the releasees or otherwise while the named Participant is, for any purpose, participating in any Parks, Recreation, & Culture Department.
Releasor(s) hereby assume full responsibility for the risk of bodily injury to the named Participant due to the negligence of releasees or otherwise while the named Participant is, for any purpose, participating in any Parks, Recreation, & Culture DepartmentProgram. Further, releasor(s) expressly acknowledge that Participant’s participation in program is inherently dangerous and involves the risk of serious injury and agree that the foregoing release is intended to be as broad and inclusive as is permitted by the law of the State of Florida.
Releasor(s) realize(s) that the City of Winter Haven carries no medical insurance covering participation in these activities.
This release constitutes a release or waiver of all claims against the City of Winter Haven, including those claims arising out of negligence of the City of Winter Haven, its elected officials, officers, agents, employees and activity supervisors. This release is signed of my/our free act and will.
Photo Consent: I hereby consent to the use of any photographs taken by the City of Winter Haven, its employees, agents, assigned and/or elected officials of myself or my children during participation in this program, class or event, for which the above Release and Waiver has been executed. I agree such photographs shall be the sole property of the City of Winter Haven and neither myself or the individual(s) on whose behalf this consent is signed are entitled to compensation of any kind for use of such photographs by the City, its employees, agents, assigns, or elected officials.
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Signature (Self, Parent or Guardian)Date