Release, Waiver, and Hold Harmless Permission to Participate
THE CITY OF BETTENDORF REQUIRES THIS FORM BE SIGNED BEFORE PARTICIPATION
IN A CITY SPONSORED ACTIVITY. IF THIS FORM IS NOT SIGNED, YOU OR YOUR CHILD WILL NOT BE
ALLOWED TO PARTICIPATE. IT IS A WAIVER OF RIGHTS.
DO NOT SIGN IF YOU HAVE ANY QUESTIONS.
1. You, for yourself and as appropriate on behalf of your child hereby agree to release, waive, and hold harmless the City of Bettendorf, the Bettendorf Community School District, agents, employees, volunteers, and contractors of either entity (Collectively referred to as “RELEASEES”) from any and all liability arising from participation in the activity you are registering for or signing a roster for.
2. This release waives all claims whatsoever, known or unknown, which may arise by virtue of participation in the activity, including injury or death to self, and damage to property, however such claim may arise, including but not limited to breaches of duty (such as breach of the duty of care) and acts of current or future negligence by Releasees, their respective officers, employees, or agents (nonexclusive examples are negligent care, supervision, or control). This release waives any claims whatsoever against the Releasees arising from the actions of any other participant in the activity or any other third party. Further, this release covers all activities immediately before and after participation, including transportation to or from the event, and waiting for rides from City or School facilities after the event.
3. The undersigned further agrees to defend and hold harmless releases, their respective officers, employees, or agents against any claim, cause, loss, cost, or damage whatsoever, including attorney fees, that arises from the above-described activity. This release is specifically intended to indemnify the Releasees from any act of negligence of the undersigned.
4. Participation involves a risk of injury. By signing this form, you represent that you have considered the risks of participation in the activity, have obtained any medical clearance necessary to participate, and are able to participate without harm to yourself or others. You represent you will use any program equipment with care for yourself, other participants, and your surroundings.
5. In the event of injury, program supervisors shall administer basic first aid, and shall summon emergency services via 911. Supervisors are not trained to provide detailed medical care, and shall not, without prior agreement, provide medications. All costs of emergency care are the responsibility of the participant/ participant’s legal guardian(s). NO INSURANCE IS PROVIDED BY THE CITY FOR INJURY TO PARTICIPANTS. All claims for reimbursement of medical care costs, including emergency transportation, are hereby waived.
6. Parents or others may take audio or video recordings of the participants. The City does not supervise or restrict recordings of public activities by third parties. You agree that photos or videos may be used in promotional materials produced by the City to encourage participation in the activity.
7. You agree to follow all rules of conduct established in conjunction with the activity. Failure to follow the rules will result in your removal from the activity, and you agree that any program fees paid will be kept and not refunded. In the event of a problem while engaged in the activity, notify the activity manager/supervisor.
8. This Release and Hold Harmless is given in partial consideration of your being allowed to participate in the activity described, and binds yourself, your personal representatives, and any heirs or assigns.
9. I have completed all information requests fully. Any answer found to be willfully untrue shall subject the applicant to forfeiture of the request, loss of online registration privilege, and further sanction as allowed by Park Board Policy or Law.
I HAVE READ THIS DOCUMENT CAREFULLY, AND UNDERSTAND IT. I AM SIGNING THIS FREELY AND WITHOUT RESERVATION OR CONDITION. (IF YOU HAVE ANY QUESTIONS ABOUT THIS DOCUMENT DO NOT SIGN IT. CONTACT AN ATTORNEY TO ASSIST YOU.)
Dated this _____ day of _______________, 20_____.
If you are signing on behalf of a minor, BOTH PARENTS MUST SIGN. In the case of a single parent home, the custodial parent must sign. If you are registering your child for class electronically, completion of the registration will be considered your consent and agreement with this document.
(signature) (print name)
Program Participant (must sign only if 18 or older)
(signature) (print name)
Parent (must sign if participant is less than 18 years old)
(signature) (print name)
Parent (must sign if participant is less than 18 years old)
