Cranston Parks & Recreation Playground Program

Transcription

1 Cranston Parks & Recreation Playground Program Please print clearly! *FOR OFFICE USE ONLY* School & Age Check # Birth Certificate Proof of Residency Health Insurance Child s Name Age Address City Zip Code Date of Birth Parent/Guardian s Name Relation Home Phone Work Phone Pager/Cell Does your child take any medications, or have any allergies/medical conditions that we should be aware of? If so, please explain: IN CASE OF INJURY, MEDICAL PROFESSIONALS WILL TRANSPORT PARTICIPANT FOR EMERGENCY TREATMENT AS SOON AS POSSIBLE. PLEASE INFORM EMERGENCY CONTACT PERSONS OF THIS INFORMATION IN CASE OF EMERGENCY. WE WILL TREAT ALL EMERGENCIES IMMEDIATE- LY AND NOTIFY PARENT OR GUARDIAN AS SOON AS POSSIBLE. **Please list emergency contacts in order of priority, keeping in mind the hours of 9:00 AM to 4:00 PM. ** **Please do NOT list blocked phone numbers, as the City of Cranston is not able to bypass these numbers. ** Contact Person Relation Phone Number

2 Please indicate when the participant will be attending. Requests for additional weeks or blocks of same days made after the start of camp MUST be arranged through the Recreation Office and not through the Playground Staff. LOCATION (Please check the site you would like your child to attend): Doric Garden City Glen Hills Hope Highlands WEEKS / DAYS ATTENDING (Please indicate when your child will be attending.) 1) Attending All Summer: All 8 Weeks 2) Per Week: Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 3) 8 Same Days: Mondays Tuesdays Wednesdays Thursdays Fridays Please fill in the following information regarding healthcare coverage for your child. This information will only be used in the event emergency personnel are needed. Health Insurance Provider: Health Insurance Subscriber: Health Insurance Policy Number: Signature Date A 50% DEPOSIT IS DUE AT REGISTRATION WITH PAYMENT DUE IN FULL BY THE FRIDAY BEFORE THE START OF CAMP.. IF FULL PAYMENT IS NOT RECEIVED BY THE START OF CAMP, THE PARTICIPANT CAN ONLY ATTEND FOR THE PERIOD OF TIME COVERED BY ANY PAYMENT(S). *** For Office Use Only *** Check Number Date Paid Amount Cross-Reference

3 AUTHORIZED PICK-UP PLEASE FILL OUT FOR ALL PROGRAMS The Cranston Parks and Recreation Department, in developing additional levels of safety, is asking all parents to provide a list of adults (other than parents/guardians) who can pick up your child at the end of the day. Each adult on the list will be asked to verify his/her identity by showing a valid driver s license to Supervisor or Head Instructor at the site. A child WILL NOT be released to any adult not on this list until confirmation has been made by the Parks and Recreation Department from a parent/guardian. The following people ARE allowed to pick up my child(ren) at the end of the day: FULL NAME RELATION TO PARTICIPANT

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5 ATM Development LLC, dba Wide World of Indoor Sports Participation Agreement MANDATORY ARBITRATION, RELEASE OF LIABILITY, WAIVER OF CLAIMS AND ASSUMPTION OF RISK BY SIGNING THIS DOCUMENT, YOU MAY BE WAIVING CERTAIN LEGAL RIGHTS FOR YOURSELF AND YOUR MINOR CHILD(REN), INCLUDING THE RIGHT TO SUE IN COURT AND THE RIGHT TO A JURY TRIAL. TO: ATM Development LLC dba Wide World of Indoor Sports, and the League of which I am a participant in ( League ) and their owners, officers, directors, agents, employees and/or representatives (collectively Releasees ): WARNING OF RISK: I am aware that sports-play, including, but not limited to, participation in trampoline jumping and related activities, is a voluntary and recreational activity intended to challenge and engage the physical, mental and emotional resources of the participant. Despite careful and proper preparation, instruction, conditioning and equipment, there is a risk of serious emotional and physical injury, including, but not limited to, head injury, paralysis, death, neck or back injury, wrist or ankle factures and other orthopedic injuries to limbs and joints. I am aware that I and/or my minor child(ren) should seek the advice of a pediatrician or physician BEFORE engaging in sports-play. I am also aware that it is impossible to foresee all the hazards and dangers of sports-play. I am aware that the unavoidable nature of sports-play involves falls, collisions with other participants of varying degrees of skill, horseplay and carelessness of participants including myself and/or my minor child(ren), failure in supervision or instruction. I am aware that these risks may be caused by ATM Development LLC dba Wide World of Indoor Sports ordinary negligence, mine or my minor child(ren)'s ordinary negligence, or the ordinary negligence of other participants and spectators in the League. These risks and dangers may also include those arising from mine or my minor child(ren)'s participation with bigger, faster and stronger participants in the League. In this regard, I recognize that accidents may happen, and it is impossible for ATM Development LLC dba Wide World of Indoor Sports to guarantee absolute safety to me and/or my minor child(ren). ASSUMPTION OF RISK: I am aware that sports-play, including, but not limited to, participation in trampoline jumping and related activities, involves certain inherent risks, dangers, and hazards, which can result in serious personal injury, paralysis or death. I am also aware that sports complexes contain potential dangers to the sports-playing public. As such, I hereby, for myself and/or, if applicable, my minor child(ren), freely and voluntarily agree to assume and fully accept any and all known and unknown risks of injury, regardless of the severity of any such injury, while either I and/or my minor child (ren) is participating in sports activities at the complex known as ATM Development LLC dba Wide World of Indoor Sports located at 621 Pound Hill Road, North Smithfield, Rhode Island (the Complex ). I further recognize and acknowledge that the risks inherent in sports-play can be greatly reduced by: using common sense to care for my own safety and the safety of all others, abiding by League and/or Complex rules/regulations, and consulting with a physician or pediatrician BEFORE I and/or my minor child(ren) engage in sports-play. RELEASE AND WAIVER OF CLAIMS AGREEMENT: As a precondition, and in consideration of allowing me to participate in the League s sports-play activities at the Complex, I hereby, for myself and if applicable, for my minor child(ren), to the fullest extent permitted by law: 1. WAIVE ANY AND ALL CLAIMS that I and/or my minor child(ren), if applicable, have or may in the future have against each of the Releasees resulting from the League s activities at the Complex and my and/or my minor child(ren)'s participation therein. 2. RELEASE each of the Releasees from any and all liability for any loss, damage, injury or expense that I or if applicable, my minor ch ild (ren) may suffer, as a result of my or my minor child(ren)'s participation in sports-play, due to any cause whatsoever, including the ordinary negligence or breach of contract on the part of the Releasees in the operation, supervision, design, or maintenance of the Complex, the ordinary negligence of other League participants or spectators, and my and/or my minor child(ren) s negligence 3. INDEMNIFY and hold harmless the Releasees against any and all liability, loss, expense, reasonable attorneys' fees, or claims for injur y or damages, in proportion to, caused by, or resulting from mine or my minor child(ren)'s acts or omissions arising out of, or connected to, my and/or my minor child(ren)'s participation in sports-play, whenever and however such acts and omissions occur. 4. I further grant ATM Development LLC dba Wide World of Indoor Sports the right, without reservation or limitation, to photograph, videotape, and/ or record me and to use my name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, and promotional materials.

6 ARBITRATION: As a further precondition and further consideration of allowing me and/or my minor child(ren) to participate in the League s sports play in the Complex, I hereby agree to submit to binding arbitration any and all claims for damages which I believe I and/or my minor child(ren) may have against any of the Releasees arising from, or connected to, the League s activities at the Complex. The arbitration shall be held before the American Arbitration Association pursuant to JAMS Comprehensive Arbitration Rules and Expedited Procedures, in accordance with JAMS Consumer Minimum Standards. Notwithstanding the provision below with respect to the applicable substantive law, any arbitration conducted pursuant to the terms of this Agreement shall be governed by the Federal Arbitration Act (9 U.S.C., Secs. 1-16). The arbitrator, and not any federal, state, or local court or agency, shall have exclusive authority to resolve any dispute relating to the interpretation, applicability, enforceability or formation of this Agreement. Arbitration shall be commenced within one (1) year from the date on which any alleged claim first arose. Further, the arbitration shall be held in the State of Rhode Island, and Rhode Island law shall apply. SEVERABILITY: I further agree that the foregoing is intended to be as broad and inclusive as is permitted by the State of Rhode Island and that, if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal effect. BINDING EFFECT OF AGREEMENT: In the event of my death or incapacity, this Agreement shall be effective and binding upon my heirs, and legal representatives, or assigns. ENTIRE AGREEMENT: In entering into this Agreement, I am not relying upon any oral or written representation other than what is set forth in this Agreement. REPRESENTATION: I represent that I or my minor child(ren), if applicable, is in good health and have no physical limitations that would prevent me or my minor child(ren) from participating in vigorous and strenuous league sports-play. ON-LINE REGISTRATION: By checking the box below shall substitute for and have the same legal effect as an original form signature. PAR- TICIPATION WILL BE DENIED if the signature of adult participant or parent/guardian of minor child(ren) and date are not on this Agreement. I HAVE READ AND UNDERSTAND THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE RELEASEES. Participant Name Date of Birth Participant Name Date of Birth Participant Name Date of Birth Signature (Parent/Guardian signature required if participant is under 18 years of age) Date Phone Address City/State/Zip Checking this box acts as your signature and your agreement with the terms and conditions of this Waiver and Release

7 SUPERIOR MARTIAL ARTS AND FITNESS WAIVER AND RELEASE FORM CRANSTON SUMMER CAMP 60 Walnut Grove, Cranston, RI PARTICIPANT NAME CELL PHONE: ( ) (First Name, Last Name) ADRESS: HOME PHONE: ( ) CITY: STATE: ZIP: Date of Birth / / MM DD YYYY MEDICAL CONDITIONS: EMERGENCY CONTACT: Full Name: Phone #: Relation: ACKNOWLEDGEMENT AND RELEASE FORM I ( Releasor )do hereby apply to participate in Martial Arts and Fitness Instruction (the Program ), Workshops and/or Seminars provided by Absolute Vision LTD., a U.S. Corporation, d/b/a SUPERIOR MARTIAL ART & FITNESS and SUPERIOR TAEKWONDO ACADEMY, at 60 Walnut Grove Ave., Cranston, Rhode Island and other training locations to be determined at the time of the individual event(s). I do hereby represent that I am in good physical health and free from any disabling physical conditions and further acknowledge that SUPERIOR MARTIAL ARTS & FITNESS, its proprietors and instructors are relying upon these representations to allow my participation in the Program. I do hereby represent that I am aware that any martial arts training, including the Program, inherently carries the risk of great bodily injury or loss of life. I do hereby voluntarily, and with full knowledge of these risks, agree to participate in the Program. In consideration for the opportunity to participate in the Program, I do hereby release Absolute Vision LTD., a U.S. Corporation, d/b/a SUPERIOR MARTIAL ART & FITNESS and SUPERIOR TAEKWONDO ACADEMY, its proprietors, instructors, agents, employees, servants, successors, assigns, owners of the property where the Program is conducted, as well as their servants, employees, agents, successors and assigns, and other participants in the Program (the Releasees ) from responsibility or liability for any loss, injury or damage, however caused, and do hereby waive, indemnify, remise, release and forever discharge the Releasees for any loss, injury or damage, including loss of life, that I may suffer as a result of my participation in the Program. In the event that I (or my parent or guardian) am unable to do so, I hereby grant Absolute Vision LTD., a U.S. Corporation, d/b/a SUPERIOR MARTIAL ART & FITNESS and SUPERIOR TAEKWONDO ACADEMY, its proprietors, instructors, employees, servants or agents, permission to seek out any necessary medical assistance that they deem I may require as a result of participating in the Program, although I understand that there is no obligation upon them to do so. This Waiver and Release and all acknowledgments, agreements and representations contained herein shall be binding upon my family, heirs, successors and assigns. I hereby acknowledge that I have read this WAIVER AND RELEASE OF CLAIMS carefully and understand and agree to its terms. Print: First Name, Last Name X / / Signature Date (MM/DD/YYYY)

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