Print and fill out then drop off at Borough Office
MINERSVILLE AREA SKATEPARK ASSOCIATION
WAIVER AND RELEASE OF LIABILITY
In consideration of being allowed to participate in any way at the Minersville Area Skatepark, I, as named below, along with my parent or guardian who signs below, acknowledge, appreciate, and agree that:
1. The risk of injury from the activities involved in at a skatepark is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISK, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES (as indicated below) OR OTHERS, and assume full responsibilities for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any unusual hazard during my presence or participation, I will remove myself from participation and bring such to the attention of a Minersville Area Skatepark Association member IMMEDIATELY and immediately stop using the park; and,
4. I, for myself and on behalf of my heirs, assign, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS the Minersville Area Skatepark Association, their officers, agents and members, other participants, sponsors, advertisers, and the owners and lessors of the real property used to conduct the activities (“Releasees as a group”), WITH RESPECT TO ANY AND ALL INJURY, DISABLITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLEGENCE OF THE RELEASEES OR OTHERWISE.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
MINOR’S NAME: _________________________________________ BIRTH DATE: __________________________
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in the activities provided above, even if arising from the negligence of the Releasees, to the fullest extent permitted by law. I am also certifying by signing that I am the parent and or guardian of the above named minor child and that I have the legal capacity to sign this waiver.
Parent/Guardian’s Name: ____________________________________________
This form MUST be returned to the Borough Office at 2 E. Sunbury Street, Minersville, PA
17954 to the attention of The Minersville Area Skatepark Association BEFORE your child can do ANY activity on the skatepark. No exceptions.