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) Notlivinginhousehold
Name Relaon
Phone Alt. Phone
Parcipant Name Birthdate Grade Gender Program # and Name Fee*
*Non‐residents add $5
Release, Waiver and Assumpon of Risk: In consideraon of acceptance of my (or my minor child's) registraon in the program(s), I do hereby, take acon 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 acons of any kind which may hereaer accrue to me, including as to my traveling to and from this
event, the following enes or persons: Waterford Township and Waterford Parks and Recreaon Department (hereaer referred to as WPR), its elected and
appointed officials, employees and volunteers, and representaves and agents, and others working or acng in behalf of Waterford Township and WPR; and to
the extent permied by law (B) Indemnify and Hold Harmless the enes or persons menoned in this paragraph from any and all liabilies or claims made by
other individuals or enes as a result of or relang to my aendance at or parcipaon in this program(s).
Photo/Video Authorizaon: I hereby give my consent for WPR to use photos/videos of myself and/or minor child parcipang in a WPR sponsored program
or event in future markeng 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 aendees must contact the photographer at the event if they wish themselves/their children not be photographed.
Assumpon of Risk Relang 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 congregaon of people in groups of various sizes. WPR has put in place preventave 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. Parcipaon 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 aending or parcipang in a WPR event and that such exposure or infecon 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 acon, omissions, or negligence or
myself and others, including but not limited to WPR, its directors, organizers, coaches, sponsors, managers, aorneys, 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 connecon with my parcipaon or aendance 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, aorneys, employees, or any other appointed supervisor from such, including all liabilies, acons, damages or expenses or any
type that may arise out of, or relang thereto aendance and parcipaon. I understand and agree that this release includes any claims regarding the acons,
omissions, or negligence or WPR, its directors, organizers, coaches, sponsors, managers, aorneys, employees, or any other appointed supervisor, whether a
COVID‐19 infecon occurs before, during, or aer parcipaon or aendance at any WPR event.
Signature of Parcipant or Parent/Guardian Print Name Date
(If parcipant is under 18 years of age)
Payment Method:
Check Payable to: Waterford Parks & Recreaon
Card Info
Visa/MC/Discover # __________________________________ CVV_________ Exp. Date ______________
Signature Required Visa/MC/Discover ___________________________________ Date_______________
Total Due
click to sign
click to edit
click to sign
click to edit