ADULT WAIVER
RELEASE, DISCHARGE OF LIABILITY AND ASSUMPTION OF RISK
Name of participant:_______________________________________________________________________
Address:___________________________________________________________________________________
Telephone: _______________________________Emergency telephone:___________________________
Name of class or activity (“the activity”): Healthy Diamond Bar / Connect with Rec
I am physically fit to participate in the activity and have not been diagnosed with any illness or
medical condition that would impair my ability to participate in the activity. No physician has
recommended against my participation.
I am aware that the activity poses a risk of injury to me, and that occasionally accidents occur
during activities of this kind. Knowing these risks, on behalf of myself, I freely and voluntarily agree
to assume all of the risks associated with participation in the activity.
In consideration of my being permitted to enroll and participate in the activity, I agree to release
and discharge the Program Sponsors from any liability, causes of action, claims or damages for
personal injury, property damage and wrongful death arising from or attributable to my
participation in the activity, whether or not such liability arises from the program sponsors’
negligence in organizing, planning and implementing the activity.
I understand that by signing this instrument, I (and my legal representatives, heirs, assigns or any
other successors in interest) am barred from presenting any claim or instituting any civil action or
present any claim for personal injury, property damage or wrongful death against the Program
Sponsors who, through negligence or otherwise, might otherwise be liable to me, or other
successors in interest for damages.
I HAVE READ THIS RELEASE CAREFULLY AND FULLY UNDERSTAND IT. I UNDERSTAND THE RISKS
INVOLVED IN THE ACTIVITY. I UNDERSTAND THAT BY SIGNING THIS RELEASE, I GIVE UP THE RIGHT TO
SUE THE PROGRAM SPONSORS. I SIGN THIS RELEASE FREELY AND VOLUNTARILY WITHOUT
INDUCEMENT.
In the event of a medical emergency, I authorize medical personnel attending to me to
make decisions regarding immediate medical treatment as may be necessary until such
time as my emergency contact can be consulted.
By registering for any recreation class or activity, I grant the City of Diamond Bar permission
to use my photograph, video or film likeness, for promotional use in any City-related media.
Participant’s Signature:
Class/Program Name: Healthy Diamond Bar / Connect with Rec Date:
