Ohio Township Parks And Recreation Program Registration Form

Ohio Township Parks and Recreation Program Registration Form

Please Print Clearly

Program Name: _________________________________________________ Program Fee: ___________________

Day(s): ______________________________________________ Time:___________________________________

Are you a Township resident? Yes ___ No ___

Participant’s Name: _____________________________________ Birth Date: ______________ Sex: M___ F___

(Last)

(First)

(mm/dd/yyyy)

Street Address: ________________________________________________________________________________

(Street)

(City)

(Zip Code)

Phone: _____________________________________ Phone 2: _________________________________________

E-mail Address: _______________________________________________________________________________

Does Participant have any medical concerns? _______________________________________________________

Emergency Contact: ___________________________________________________________________________

(Name)

(Relationship to participant)

(Phone Number)

How did you hear about the program? _____________________________________________________________

WAIVER

In consideration of and agreeing to, on behalf of both myself, on my membership account, and my minor child(ren), participate in recreation and fitness activities with the Ohio

Township Recreation Department, I agree as follows: I fully understand and acknowledge that recreational and fitness activities have; (a) inherent risks, dangers, and hazards

and such exists in the use of any equipment and the participation in these activities; (b) both my own and my minor child(ren)’s participation in such activities and/or use of

such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that,

could cause serious disability; (c) these risks and dangers may be caused by the negligence of the agents, officers, representatives, employees, or volunteers of the Township of

Ohio and the Ohio Township Recreation Department, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes; (d) in

consideration of and by my participation and my minor child(ren)’s participation in these activities and for both my and their use of equipment, I hereby (and also on behalf of

my minor child(ren)) voluntarily assume all risks and dangers and all responsibility for any injuries, losses and/or damages of any kind whatsoever, whether caused in whole or

in part by the negligence or the conduct of the agents, officers, representatives, employees, or volunteers of the Township of Ohio and the Ohio Township Recreation

Department, or by any other person.

I, on behalf of myself, my minor child(ren), my personal representatives and my heirs, executors, and administrators, hereby voluntarily agree to release, waive, discharge, hold

harmless, defend, and indemnify the Township of Ohio and the Ohio Township Recreation Department and their agents, officers, representatives, employees, and volunteers

from any and all demands, claims, causes of action, liability, or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise from

any cause whatsoever and including those arising in any way from my or my minor child(ren)’s use of any equipment or participation in these activities. I specifically

understand that I am releasing, discharging, and waiving any demands, claims or causes of action that I or my minor child(ren) (or my above-stated representatives) may have

presently or may have in the future for the negligent acts or other conduct by the agents, officers, representatives, employees, and volunteers of the Township of Ohio and of

the Ohio Township Recreation Department.

Intending to be legally bound, I have read and understand the above waiver and release and by signing it voluntarily agree to its terms. It is my express intention to exempt and

release and hold harmless the Township of Ohio, and the Ohio Township Recreation Department and their agents, officers, representatives, employees, and volunteers, from

any and all liability for personal injury, property damage or wrongful death (to either myself, or to my minor child(ren)) caused by their negligence or by any other cause.

_________________________________________________

________________________________

Participant’s Signature

Date

_________________________________________________

________________________________

Parent/Guardian Signature if under age 18

Date

Checks should be made payable to Ohio Township.

Remit registration and payment to:

Ohio Township

Attn: Andy Rubino

1719 Roosevelt Road

Pittsburgh, PA 15237