Gary Wall, Supervisor
Kim Markee, Clerk
Margaret Birch, Treasurer
Anthony M. Bartolotta, Trustee
Arthur Frasca, Trustee
Karen Joliat, Trustee
Steven Thomas, Trustee
5200 Civic Center Drive
Waterford, Michigan 48329-3773
Telephone: (248) 674-5441 Fax: (248) 618-7674
Department of Parks & Recreation
Alison Swanson, Directo
Recreation Board Members
Donna Kelley, Chairperson
Jerry Beseau
Allison Buczek
Dan Ludwig
Kim Markee
J.R. Olerich
Rob Petrusha
Linda Zabik
Parental Waiver, Release of Liability, Indemnification and Consent Form
I represent to the Charter Township of Waterford that I am aware of no physical or mental restrictions that would
prevent my child from safely participating in any Waterford Parks and Recreation Department activity.
I acknowledge that these activities are potentially dangerous and involve the risk of injury, death or property
I assume full responsibility of any risk of injury, death, or property damage related to these activities.
In consideration of my child’s participation in the program, I agree that my child’s likeness may be photographed or
videotaped and that such image may be published in any outlet used to promote or publicize the program.
I am the parent (or legal guardian) of My Child. My Child is attending or participating in the event described below.
In the event of an emergency affecting the life or permanent well-being of My Child, I authorize any licensed
physician, emergency medical technician, paramedic, nurse, hospital or other medical facility to treat My Child,
including the authority to admit My Child to the hospital and provide medical and hospital care and treatment for My
Child, including having surgery, anesthesia, blood and blood products, if necessary.
I understand that by executing this form I am not relieved of any financial or other obligation regarding My Child for
which I am legally responsible.
In consideration for my child’s participation in the activity or activities, I waive any rights I may have against the
Charter Township of Waterford, their appointed and elected officials, employees, volunteers, attorneys, assigns,
agents and successors concerning this activity or these activities, including transportation (if provided by the
program) and the use of photographs for promotion as described above. I release and discharge, the Charter
Township of Waterford their appointed and elected officials, employees, volunteers, attorneys, assigns, agents and
successors of and from all claims debts, attorney fees, costs, actions and causes of action of any kind connected
with this activity or these activities.
I acknowledge that I will review the Youth Sports Concussion Information prior to my child’s participation in this
Name of League Sport Date
Name of Child (Print) Name of Parent or Legal Guardian (Print)
Signature of Parent
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