CITY OF NEWARK PARKS & RECREATION
ACTIVITY REGISTRATION FORM
RESIDENT - YOU PAY CITY OF NEWARK TAXES NON-RESIDENT - YOU DO NOT PAY CITY OF NEWARK TAXES
RESPONSIBLE ADULT
PARTICIPANT INFORMATION
ADDITIONAL INFORMATION
SIGNATURE: DATE:
FIRST NAME
FIRST NAME
ACTIVITY NUMBER
ACTIVITY NUMBER
I or in my legal capacity as the parent/guardian of the minor named hereby acknowledge and agree that participation in Newark Parks and Recreation activities comes with inherent risks. I have full knowledge and
understanding of the inherent risks associated with Newark Parks and Recreation participation, including but in no way limited to: (1) slips, trips, and falls, (2) aquatic injuries, (3) athletic injuries, and (4) illness, including
exposure to and infection with viruses or bacteria. I further acknowledge that the preceding list is not inclusive of all possible risks associated with participation and that said list in no way limits the operation of this
Agreement.
CORONAVIRUS / COVID-19 WARNING & DISCLAIMER
Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a mean to prevent the spread of the virus.
COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in Newark Parks and Recreation programs or accessing City of Newark facilities could increase the risk of contracting
COVID-19. The City of Newark in no way warrants that COVID-19 infection will not occur through participation in Newark Parks and Recreation programs or accessing City of Newark facilities.
WAIVER, RELEASE, INDEMNIFICATION & COVENANT NOT TO SUE
In consideration of participation in Newark Parks and Recreation programs, events and activities I, the undersigned participant or parent/guardian of minor(s) named agree to release and on behalf of myself, and the minor(s)
named, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE the City of Newark, its ocers, directors, employees, volunteers, agents, representatives and insurers (“Releasees”) from any
causes of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, and including, inter alia, claims stemming from exposure to the COVID-19 virus, which I, the named
minor, my heirs, representatives, executors, administrators and assigns may have, now or in the future, against Newark Parks and Recreation on account of personal injury, property damage, death or accident of any kind,
arising out of or in any way related to the use of City of Newark facilities/equipment or participation in Newark Parks and Recreation programs whether that participation is supervised or unsupervised, however the injury
or damage occurs, including, but not limited to the negligence of Releasees.
In consideration of my or the named minor(s) participation in Newark Parks and Recreation programs, I, the undersigned participant or parent/guardian of named minor(s), agree to INDEMNIFY AND HOLD HARMLESS
Releasees from any and all causes of action, claims, demands, losses, or costs of any nature whatsoever arising out of or in any way related to my or the named minor(s) participation. I hereby certify on behalf of myself and
the named minor(s) that I have full knowledge of the nature and extent of the risks inherent in Newark Parks and Recreation participation and that I, on behalf of myself and the named minor(s) am voluntarily assuming said
risks. I understand that I and the named minor(s) will be solely responsible for any loss or damage, including personal injury, property damage, or death, I or the named minor(s) sustain while participating in Newark Parks
and Recreation programs and that by signing this agreement I on behalf of myself and the named minor(s) HEREBY RELEASE Releasees from all liability for such loss, damage, or death. I further certify that I and the named
minor(s) are in good health and have no conditions or impairments which would preclude safe participation in Newark Parks and Recreation programs. I understand that the City of Newark provides NO insurance coverage
for this activity. I give permission for myself and/or named minor to be photographed while participating and/or attending a Newark Parks & Recreation activity. I understand that photos may be used in future publicity.
PLEASE RETURN THIS FORM WITH PAYMENT TO THE PARKS AND RECREATION OFFICE.
220 SOUTH MAIN STREET, NEWARK DE, 19711 • (302) 366 7000 • FAX (302) 366-7169
Please note: The activities oered by the Newark Parks & Recreation Department are accessible to individuals
with disabilities. If there are any reasonable accommodations that we might need to make for the participant to
fully participate in our activities, please call the Parks & Recreation oce to discuss the matter.
Does participant have any allergies? Yes No If yes, please explain:
Does participant have any physical or mental conditions that may require special attention? Yes No
If yes, explain:
ACTIVITY NAME
ACTIVITY NAME
ACTIVITY FEE
ACTIVITY FEE
FEE TOTAL:
$
BIRTHDAY (M, D, Y)
BIRTHDAY (M, D, Y)
MAILING ADDRESS
CITY
HOME PHONE CELL PHONE
EMAIL ADDRESS
WORK PHONE
LAST NAME
LAST NAME
AGE
.
.
SEX
ZIP
STATE
M.I.
EMERGENCY RELEASE WAIVER • MUST ACKNOWLEDGE AND SIGN
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signature
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