CITY OF CLERMONT
Parks & Recreation Department
3700 S. Highway 27, Clermont, FL 34711
PLEASE PRINT LEGIBLY
REGISTRATION FORM FOR ADULTS 18 YEARS OF AGE OR OLDER
PROGRAM NAME:
SESSION DATE:
ARE YOU REGISTERING FOR A 55+ PROGRAM?
YES
NO
PARTICIPANT INFORMATION
F
IRST
N
AME
MI
L
AST
N
AME
DDRESS
C
ITY
ST
Z
IP
HOME PHONE
CELL PHONE
E
MAIL
A
DDRESS
SEX
M
F
PHOTO PERMISSION
I hereby
Agree
Disagree
(Check one)
To give my consent to be photographed by the City of Clermont for the purposes of advertising and/or public display
EMERGENCY CONTACT INFORMATION
I understand every effort will be made to contact the alternate emergency contact of program participants. In the event I cannot be
reached, I hereby give permission to the physician or emergency services selected by the Program Director to make arrangements
for medical care for myself/child/ward.
PARTICIPANT SIGNATURE
DATE
A
LTERNATE
E
MERGENCY
C
ONTACT
P
HONE
LIST ANY HEALTH ISSUES/ALLERGIES/ACTIVITY RESTRICTIONS/MEDICATIONS:
Please sign the waiver and release form on reverse side
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signature
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City of Clermont Waiver and Release for Recreational Programs
IMPORTANT INFORMATION
The City of Clermont is committed to conducting its recreation programs and activities in a safe manner and holds the safety
of participation in high regard. The City of Clermont continually strives to reduce such risks and insist that all participants and
parents/guardians of minors registering for the listed programs/activities must recognize that there is an inherent risk of injury
when choosing to participate in recreational activities/programs.
You are solely responsible for determining if you or your minor child/ward is physically fit and/or skilled for the activities
contemplated by this agreement. It is always advisable, especially if the participant is pregnant, disable in any way or recently
suffered an illness, injury or impairment, to consult a physician before undertaking any physical activity.
WARNING OF RISK
Recreational activities/programs are intended to challenge and engage the physical, mental, and emotional resources of each
participant. Despite careful and proper preparation, instruction, medical advice, conditioning and equipment, there is still a
risk of serious injury when participating in any recreational activity/program. Understandably, not all hazards and dangers
can be foreseen. Depending on the particular activity, participants must understand that certain risks, dangers, and injuries
due to inclement weather, slipping, falling, poor skill level or conditioning, carelessness, horseplay, unsportsmanlike conduct,
premises defects, inadequate or defective equipment, inadequate supervision, instruction, or officiating, and all other
circumstances inherent to indoor and outdoor recreational activities/programs exists. In this regard, it must be recognized
that it is impossible for the City of Clermont to guarantee absolute safety.
WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK
Please read this form carefully and be aware that in signing up and participating in the identified programs/activities, you will
be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages, or loss which you
or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with
said programs/activities (including transportation services/vehicle operation, when provided).
I recognize and acknowledge that there are certain risks of physical injury to participants in these program/activities, and I
voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my child/ward or
I may sustain as a result of said participation. I further agree to waive and relinquish all claims my minor child/ward or I may
have (or accrue to my child/ward or me) as a result of participating in these programs/activities against the City of Clermont,
including its officials, agents, volunteers, and employees.
I do hereby fully release and forever discharge the City of Clermont from any and all claims for injuries, damages, or loss that
my minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or
in any way associated with these programs/activities.
PRINT NAME OF PARTICIPANT
SIGNATURE OF PARTICIPANT
DATE
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signature
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