Campbell Skate Park Liability Release

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Participant #: _______
CAMPBELL SKATE PARK
LIABILITY RELEASE
All users must submit this signed form before being allowed to skate at this facility.
FIRST NAME:
LAST NAME:
has my permission to participate at the Skate Park facility.
MEDICAL RELEASE:
Pursuant to the provisions of sections 6910 et seq of the California Family Code,
and other applicable laws, I hereby authorize the City of Campbell Recreation & Community Services Department
to procure, and consent to, medical or dental care for myself or my child in the event of injury as a result of use of
the Campbell Skate Park.
WAIVER and RELEASE of LIABILITY:
In consideration of my participation, I hereby release,
discharge and covenant not to sue the City of Campbell and/or the Campbell Redevelopment Agency, their
officers, employees, and volunteers, from any and all present and future claims, demands, actions or causes of
action resulting from any accidents, injuries, deaths, or loss of and/or damage to my/our person(s) or property
arising out of or connected with my/our participation in the above activity except for claims legally caused by the
sole negligence or willful misconduct of the City or other listed (above). I hereby voluntarily waive any and all
claims resulting from ordinary negligence, both present and future, that may be made by me, my family, estate,
heirs or assigns.
Further, I am, aware that this activity may involve certain risks or possible dangers, including death, and
that equipment provided for my protection may be inadequate to prevent serious injury.
I am voluntarily
participating in this activity with knowledge of the danger involved and hereby agree to accept any and all inherent
risks of property damage, personal injury, or death.
I further agree to indemnify and hold harmless the City of Campbell and others above for any and all
claims arising as a result of my engaging in this activity. I understand that this waiver will continue in full legal
force and effect. I further agree that the venue for any legal proceedings shall be in California.
I affirm that I am of legal age and am freely signing this document. I have read this form and fully
understand that by signing this form, I am giving up legal rights and /or remedies that may be available to me
against the City of Campbell or any of the parties listed above.
X____________________________________________
Date:_________________________
Signature of adult or legal guardian of participant
Print Name: _____________________________
Check One: Participant ___ Parent___ Guardian___
Name of adult or legal guardian of participant
Required Participant Information:
Home
Address: _________________________________
City/Zip____________________________
Home Phone #: ____________________________
Age:
__________
Emergency Phone #
in case of injury: _________________________
School: __________________________
(Required if participant is under 18)
Hospital of choice for emergency care: ________________________________________________
Does participant have any known allergies? ____________________________________________
Campbell Recreation & Community Services Department
Mailing Address: 1 West Campbell Avenue #C-31 Campbell, CA 95008-1039
TELEPHONE: 866-2105
FAX: 374-6965
TDD: 866-2790

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