Revised 4/10/2007

ACCIDENT RELEASE AND FINANCIAL RESPONSIBILITY WAIVER

I AM AWARE OF THE RECREATIONAL PROGRAMS PROVIDED BY THE CITY OF SATELLITE BEACH RECREATION DEPARTMENT, AND UNDERSTAND THE INHERENT DANGERS INVOLVED WITH MY PARTICIPATION IN THESE PROGRAMS AND THE DANGERS INVOLVED IN TRANSPORTATION TO AND FROM THESE PROGRAMS, INCLUDING THE RISK OF DEATH AND/OR PERSONAL INJURY OR DAMAGE TO MYSELF AND/OR MY PROPERTY WHILE PARTICIPATING IN SUCH PROGRAMS.  I FURTHER UNDERSTAND AND ACKNOWLEDGE THAT PARTICIPANTS IN SUCH PROGRAMS ARE NOT COVERED UNDER  INSURANCE  OF THE CITY, AND THAT THE CITY WOULD NOT ALLOW MY PARTICIPATING IN SUCH PROGRAMS ABSENT MY SIGNING THIS RELEASE.  I THEREFORE FREELY AND VOLUNTARILY EXECUTE THIS RELEASE AND WITH SUCH KNOWLEDGE, ASSUME  THE RISK OF DEATH, PERSONAL INURY AND/OR PROPERTY LOSS ARISING FROM OR IN ANY WAY CONNECTED WITH MY PARTICIPATION IN ANY RECREATION PROGRAM OFFERED BY THE CITY OF SATELLITE BEACH.

 

I AUTHORIZE AND GRANT PERMISSION TO THE REPRESENTATIVE OF THE CITY OF SATELLITE BEACH RECREATION DEPARTMENT TO OBTAIN MEDICAL CARE FROM ANY LICENSED PHYSICIAN OR HOSPITAL AND/OR MEDICAL CLINIC SHOULD I BECOME ILL OR INJURED WHILE PARTICIPATING IN RECREATION ACTIVITIES AWAY FROM HOME, OR AT  OTHER TIMES WHEN NEITHER PARENT NOR GUARDIAN IS AVAILABLE TO GRANT AUTHORIZATION FOR EMERGENCY TREATMENT.

 

I HEREBY RELEASE AND FOREVER DISCHARGE THE CITY OF SATELLITE BEACH, THE CITY OF SATELLITE BEACH RECREATION DEPARTMENT AND ANY AND ALL AGENTS OF THE DEPARTMENT FROM ANY LIABILITY, CLAIM, CAUSE  OF ACTION, DEMAND OR DAMAGES FOR INJURY, DEATH OR DAMAGES OF ANY KIND TO ME OR TO MY PROPERTY AS A RESULT OF MY PARTICIPATION IN THE RECREATION PROGRAMS OF THE CITY OF SATELLITE BEACH RECREATION DEPARTMENT.  I FURTHER WAIVE, RELEASE, ABSOLVE AND AGREE TO INDEMNIFY AND HOLD THE CITY HARMLESS, AS A RESULT OF MY PARTICIPATION IN ANY RECREATIONAL PROGRAM SPONSORED BY THE CITY OF SATELLITE BEACH.

 

BY SIGNING BELOW, I ACKNOWLEDGE HAVING READ THE CITY OF SATELLITE BEACH’S ACCIDENT RELEASE AND FINANCIAL RESPONSIBILITY WAIVER. 

DATE

SIGNATURE

PRINT YOUR NAME

STUDENT/CHILD NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  Instructions:

Parents or Legal Guardians Only Can Sign:                                         Mail to:

          Insert Date in First Column                                                            Satellite Beach Recreation Dept.

          Sign your name in Second Column                                                1089 S. Patrick Ave.

          Print your name in Third Column                                                    Satellite Beach, FL  32937

          Print your Children’s name in the Fourth Column                                (321) 773-6458

          (or insert “self” if you are the student)

          Return with your registration information.                                   

 

Sorry - this form CANNOT be faxed - we must have an original

signature.  Please complete and either mail or hand deliver.