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RELEASE
FORM
On
behalf of myself, my Personal Representative, heirs and
assigns, I agree and acknowledge that I am participating
in the Island Community Center sponsored activity of my
own accord. I give this acknowledgement freely and knowingly
and I represent and warrant that I am physically and mentally
fit and that, as a result, able to participate, and I
do hereby assume all responsibility for my well-being.
The Island Community Center sponsored activity is described
on the attached page.
I am fully aware that injury might occur to me as a result
of my participation and I agree to assume all risk, including
risk which is not specifically foreseeable, of any injuries,
including death, damages or loss regardless of severity,
which I may sustain as a result of participation in this
event against the Towns of Stonington and Deer Isle, the
Island Community Center and its respective members and
Directors, Selectmen, Town Manager, officers, employees,
staff and all individuals assisting in instructing, chaperoning,
participating in and conducting these activities, individually
and collectively, and I hereby fully release and discharge
them and each of them, from any and all claims resulting
from injuries, including death, damage or loss, which
I sustain arising out of or in anyway connected with my
participation in this activity Specifically, I hereby
release the Towns of Stonington and Deer Isle and the
Island Community Center and its respective members and
trip chaperones from their own acts of negligence as respects
this Island Community Center activity.
I agree to indemnify, defend and hold harmless the towns
of Stonington and Deer Isle and the Island Community Center
and its respective members and any other sponsors or chaperones
from any and all claims that result from injuries, including
death, damage or loss, which I may sustain arising out
of or in any way connected with my participation in the
above described Island Community Center activity and
shall indemnify, defend and hold harmless the Towns of
Stonington and Deer Isle and the Island Community Center
and its respective members and trip chaperones from their
own acts of negligence arising out of or in any way connected
with this activity.
Signed: (Participant)____________________________________________
Date of Birth:_______________________
Activity:
Activity Date:
Signature of Parent
(If participant is under 18):
_______________________________________
Telephone#_______________________
Health Insurance Company_________________________________
Policy #_____________________________
By my signature above and in the event I cannot be contacted,
I hereby authorize that emergency medical treatment, if
required, be administered to my child: ___________________________________________.
The Island Community Center expects all participating
to behave appropriately and in a sportsmanlike and courteous
manner. Inappropriate behavior could jeopardize future
participation. Please discuss this policy with your child.
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