5200 Civic Center Drive, Waterford, MI 48329
Phone (248) 674‐5441 Fax (248) 618‐7674
www.waterfordmi.gov/parks parksinfo@waterfordmi.gov
Head of Household (First/Last Name) Birthdate Gender
Address Apt #
City Zip Email
Phone (Primary) Phone (Secondary)
Emergency Contact #1 (Required)
Name Relaon
Phone Alt. Phone
Emergency Contact #2 (Required) Notlivinginhousehold
Name Relaon
Phone Alt. Phone
Parcipant Name Birthdate Grade Gender Program # and Name Fee*
*Non‐residents add $5
$
$
$
$
ACCIDENT WAIVER, RELEASE OF LIABILITY AND INDEMNITY/HOLD HARMLESS AGREEMENT
Release, Waiver and Assumpon of Risk: In consideraon of acceptance of my (or my minor child's) registraon in the program(s), I do hereby, take acon for
myself, my executors, administrators, heirs, next of kin, successors, and assigns to: (A) Waive, release, and discharge from any and all liability for my death,
disability, personal injury, property damage, property the, or acons of any kind which may hereaer accrue to me, including as to my traveling to and from this
event, the following enes or persons: Waterford Township and Waterford Parks and Recreaon Department (hereaer referred to as WPR), its elected and
appointed officials, employees and volunteers, and representaves and agents, and others working or acng in behalf of Waterford Township and WPR; and to
the extent permied by law (B) Indemnify and Hold Harmless the enes or persons menoned in this paragraph from any and all liabilies or claims made by
other individuals or enes as a result of or relang to my aendance at or parcipaon in this program(s).
Photo/Video Authorizaon: I hereby give my consent for WPR to use photos/videos of myself and/or minor child parcipang in a WPR sponsored program
or event in future markeng materials. I acknowledge those pictured will only be named with their consent, or parent/guardian consent if younger than 18 years
of age. I acknowledge event aendees must contact the photographer at the event if they wish themselves/their children not be photographed.
Assumpon of Risk Relang to Coronavirus/COVID‐19: The coronavirus or COVID‐19 is extremely contagious and thought to have caused a worldwide
pandemic. It can readily be spread from person‐to‐person contact, or contact with infected surfaces or areas. In response, Federal, State, and local
governments, and governmental health agencies have recommended, or even required people engage in social distancing protocols as well as have prohibited
the congregaon of people in groups of various sizes. WPR has put in place preventave measures to limit the spread of the COVID‐19; however, WPR cannot
guarantee that you or your family members will not become infected with COVID‐19. Parcipaon in a WPR event can increase your risk of being exposed to the
COVID‐19 virus. I acknowledge the extremely contagious nature of COVID‐19 and voluntarily assume the risk that I may be exposed to, or infected by COVID‐19
through my aending or parcipang in a WPR event and that such exposure or infecon may result in personal injury, illness, permanent disability, and/or
death. I understand that the risk of becoming exposed to or infected by COVID‐19 at any WPR event may result from the acon, omissions, or negligence or
myself and others, including but not limited to WPR, its directors, organizers, coaches, sponsors, managers, aorneys, employees, or any other appointed
supervisor. I voluntarily agree to assume all risks and accept as my sole responsibility any injury to myself (including, but not limited to, personal injury, disability,
and/or death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connecon with my parcipaon or aendance at
any WPR event. On my behalf, and on behalf of my heirs, I hereby release, covenant not to sue, discharge, and hold harmless WPR, its directors, organizers,
coaches, sponsors, managers, aorneys, employees, or any other appointed supervisor from such, including all liabilies, acons, damages or expenses or any
type that may arise out of, or relang thereto aendance and parcipaon. I understand and agree that this release includes any claims regarding the acons,
omissions, or negligence or WPR, its directors, organizers, coaches, sponsors, managers, aorneys, employees, or any other appointed supervisor, whether a
COVID‐19 infecon occurs before, during, or aer parcipaon or aendance at any WPR event.
Signature of Parcipant or Parent/Guardian Print Name Date
(If parcipant is under 18 years of age)
Payment Method:
Cash
Check Payable to: Waterford Parks & Recreaon
Charge
Credit
Card Info
Visa/MC/Discover # __________________________________ CVV_________ Exp. Date ______________
Signature Required Visa/MC/Discover ___________________________________ Date_______________
Total Due
$
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