Town of Boxborough
RELEASE FROM LIABILITY INDEMNITY
AND HOLD HARMLESS AGREEMENT (required)
I, in consideration of my participation in Council on Aging Virtual
Programs do for RELEASE, acquit, discharge and covenant to hold harmless the Town of Boxborough
(“Town”), a municipal corporation of the Commonwealth of Massachusetts, and its successors,
departments, officers, employees, servants, attorneys and agents, of and from any and all actions, cause
of action, claims, demands, damages, costs, loss of services, expenses and compensation on account of
or in any way arising out of, directly or indirectly, all known and unknown personal injuries or property
damage which I may now or hereafter have or may acquire, resulting or to result from said participation
in the aforementioned activities. Furthermore, I hereby agree to protect the Town and its successors,
departments, officers, employees, servants, attorneys and agents from any injury to any party in
connection with said participation in the aforementioned activities and to INDEMNIFY, reimburse or
make good to the Town or its successors, departments, officers, employees, servants and agency any
loss or damage or costs, including attorneys’ fees, which the Town or its representatives may have to
pay if any litigation arises from said participation in the aforementioned activities. I understand that I
am signing up for virtual exercise classes and I am responsible for monitoring myself to take breaks
and modify exercises as needed.
Digital signature: Date:
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Emergency Authorization (required)
Medical authorization & physical condition identification:
I authorize whatever medical care may be necessary in the event of an emergency. I acknowledge that
insurance is not provided by the Town of Boxborough, the Council on Aging, its staff or volunteers for
this program. I accept the responsibility for payment of any medical expense.
Digital signature: Date:
Type your name above
Optional Photo Release
I, hereby authorize the Town of Boxborough's Council on
Aging to publish photographs taken during programs. I acknowledge that since participation in
publications and the town website produced by the Town of Boxborough is voluntary, I will not receive
financial compensation. I further agree that participation in any publications and website produced by
the Town confers no rights of ownership whatsoever.
Digital signature: Date:
Type your name above
Return these registration and release from liability forms to Council on Aging, Town Hall,
Boxborough, MA 01719
