illcreek
MILLCREEK TOWNSHIP - RECREATION & PARKS
WINTER 2021 2022 Please use this form for all activities .
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______________________________________________________________________________________________________________________________________________ FAMILY LAST NAME ( Child name if different than parent ) HOME PHONE WORK PHONE
______________________________________________________________________________________________________________________________________________ m Mr . m Mrs . m Ms . ADDRESS ZIP CODE FIRST NAME AGE ACTIVITY LOCATION DAY TIME FEE
______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________
ATTENTION : Please list any medication ( s ) your child is currently taking or needs to be administered during our programs . Please list any health or behavior related conditions for which your child is being treated .
______________________________________________________________________________________________________________________________________________ NAME
MEDICATIONS / CONDITION
Please make checks payable to : Millcreek Township Supervisors / Please sign waiver Please mail registration and signed waiver to : MILLCREEK RECREATION AND PARKS DEPARTMENT , MILLCREEK MUNICIPAL BUILDING , 3608 WEST 26TH ST ., ERIE , PA 16506 * All checks returned to us after deposit will be assessed a non-sufficient funds ( NSF ) fee .
MILLCREEK TOWNSHIP ACKNOWLEDGMENT — ASSUMPTION OF RISK , RELEASE , AND INDEMNITY AGREEMENT
This is a legally binding document . It waives and releases certain legal rights . Please read it carefully before signing it . I or my minor child wish to participate in programs offered by Millcreek Township and Millcreek Township ’ s Recreation and Parks Department ( hereafter “ Released Parties ”). Released Parties also includes the Millcreek Township School District when programs are held on the District ’ s property and / or in its facilities . Released Parties also include the officers , directors , managers , officials , trustees , agents , employees , or other representatives of each entity . On behalf of myself and my minor child listed below , I give permission to attend and participate in the program for which application is attached . 1 . I represent that I understand the nature of the program , for which application is attached , and that I or my minor child are qualified , in good health and in proper physical condition to participate in such program . I acknowledge and agree that if I believe any condition of the program is unsafe , that I or my minor child will immediately discontinue participation in the program . 2 . I understand and acknowledge that my or my minor child ’ s participation in the program for which application is attached exposes me or my minor child to risk of personal injury , including but not limited to serious personal injury and / or death , and loss or damage to personal property . I understand that the dangers and risks of practicing or participating in the program for which the application is attached may not only result in serious injury , but in a serious impairment of my future abilities to earn a living , to engage in other business , social , and recreational activities , and generally to enjoy life . I accept , on my behalf and / or on behalf of my minor child , all the risks of participating in or observing such programs , even if they are created by the carelessness or negligence of a Released Party or anyone else . The risks to which I or my minor child may be exposed include , but are not limited to accidental injury from any equipment used in the activity . I EXPRESSLY AND VOLUNTARILY ASSUME ON BEHALF OF MYSELF AND / OR MY MINOR CHILD ALL RISK OF PERSONAL INJURY , DEATH OR PROPERTY DAMAGE that may result from my participation or my minor child ’ s participation in all such programs operated by the Released Parties . 3 . COVID-19 . The novel coronavirus , COVID-19 , has been declared a worldwide pandemic by the World Health Organization .
I ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND FULLY UNDERSTAND THIS ACKNOWLEDGMENT , ASSUMPTION OF RISK , RELEASE AND INDEMNITY AGREEMENT . I HAVE HAD ALL OF MY QUESTIONS ANSWERED TO MY SATISFACTION BY MILLCREEK TOWNSHIP , THE RECREATION AND PARKS DEPARTMENT , AND KNOWINGLY AND WILLINGLY ASSUME ALL RISKS . I INTEND TO BE LEGALLY BOUND BY THIS AGREEMENT .
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Signature of PARTICIPANT Print Name Date
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Signature WITNESS Print Witness Name Date
IF STUDENT / PARTICIPANT IS UNDER 18 YEARS OF AGE : As parent / guardian of ( Please Print Child ' s Name )
Intending to be legally bound , I on behalf of the minor-participant , hereby agree to all terms and provisions stated on the above portion of this form .
Parent / Guardian Name ( Please Print ): Parent / Guardian Signature :
28 MILLCREEK
COVID-19 is extremely contagious resulting in symptoms that may be mild to symptoms that may result in death . As a result , federal , state , and local governments and federal and state health agencies recommend social distancing , frequent hand-washing and masking where possible . The Released Parties have put in place preventative measures aimed at reducing the spread of COVID-19 ; however , they cannot guarantee that you or your child will not become infected with COVID-19 while participating in any program . Further , attending programs operated by the Released Parties may increase your risk and your child ’ s risk of contracting COVID-19 . ASSUMPTION OF RISK : I have read and understood the above warning concerning COVID-19 . I or on behalf of my minor child hereby choose to accept the risk of contracting COVID-19 for myself and / or my minor child in order to utilize programing offered by the Released Parties . These programs are of such value to me and / or to my child , that I accept the risk of being exposed to , contracting , and / or spreading COVID-19 in order for me and / or my minor child to participate in programming operated by the Released Parties . WAIVER OF LAWSUIT / LIABILITY : I hereby forever release and waive my right to bring suit against the Released Parties in connection with exposure , infection , and / or spread of COVID-19 related to participating in programming operated by the Released Parties . I understand that this waiver means I give up my right and my minor child ’ s right to bring any claims including for personal injuries , death , disease or property losses , or any other loss , including but not limited to claims of negligence and give up any claim I or my minor child may have to seek damages , whether known or unknown , foreseen or unforeseen . COMPLIANCE WITH SAFETY GUIDELINES . I am familiar with federal , state , and local laws , orders , directives , and guidelines related to COVID-19 , including the Centers for Disease Control and Prevention ( CDC ) guidance on COVID-19 . I or my minor child will comply with all such orders , directives , and guidelines while participating in the program , including , without limitation , requirements related to hand sanitation , social distancing , and use of face coverings . I or my minor child will also follow all instructions of the Released Parties and / or while participating in the program . I or my minor child agree not to attend the program if I or my minor child is experiencing symptoms of the COVID-19 ( such as cough , shortness of breath , fever or any other symptom identified by the Centers for Disease Control , have a confirmed or suspected case of COVID-19 , or have come in contact in the last fourteen ( 14 ) days with a person who has been confirmed or suspected of having COVID-19 . 4 . In consideration for the opportunity for me or my minor child to participate in the programs operated by the Released Parties , I and my heirs , executors , administrators , successors , assigns and personal representatives , hereby RELEASE AND DISCHARGE the Recreation and Parks Department of Millcreek Township , Millcreek Township and the Millcreek Supervisors , and their officers , directors , employees , agents , independent contractors , volunteers and affiliates ( also included within the definition of “ Released Parties ”) from any and all liability , known or unknown , past , present , or future , for personal injury , death , property damage , medical expenses , or other losses CAUSED BY THE NEGLIGENCE OR STRICT LIABILITY of the Released Parties , and I hereby RELEASE AND WAIVE such claims on behalf of myself and / or on behalf of my minor children . 5 . I also agree NOT TO SUE OR MAKE A CLAIM AGAINST THE RELEASED PARTIES now or at any time in the future , or allow anyone to do so on my behalf or on behalf of my minor child , for personal injury , death , or property damage sustained as a result of my or my minor child ’ s participation . I will indemnify and hold harmless the Released Parties from all claims , judgments and costs , including attorneys ’ fees , incurred in connection with any such claim or claims . 6 . I fully understand and agree that the Released Parties , at their sole discretion , may terminate my or my minor child ’ s involvement as a participant at any time and for any reason . 7 . I verify that no warranties or representations have been made to me concerning the activities both stated and not stated in this Agreement . I understand and intend that this document act as the broadest and most inclusive assumption of risk , waiver , release of liability , agreement not to sue and indemnity as permitted by the laws of the Commonwealth of Pennsylvania . If any portion of this Agreement is held to be invalid , I agree that the rest of it shall continue in full force and effect .
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