☐Durham Parks and Recreation assumption of risk and liability All persons participating in Durham Parks and Recreation programs do so at their own risk and without recourse to the Town of Durham, it's agents, officers or employees. I, the undersigned participant, parent or guardian, do hereby agree to allow the individual(s) named above to participate in the activity listed, and I further agree to hold the Town of Durham Parks and Recreation Department harmless from and against any and all liability for any injury which may be suffered by the aforementioned individual arising out of his/her participation in this activity. I, understand that in case of injury or illness, I will be notified. If it is impossible to contact me and if it is an emergency, I hereby give permission to the attending physician to treat, hospitalize, administer anesthesia, or to order injections or surgery for the safety of my child. I, the parent/legal guardian, the undersigned have read this release and understand all its terms. I execute this release voluntarily and with full knowledge of its significance. I have executed this release on this date. The Durham Parks and Recreation Department may be taking pictures during any programs for use in future publications. ☐ORCSD ASSUMPTION OF RISK AND LIABILITY 1. I understand the nature of the ORCSD Summer R.E.A.C.H. Program 2019 activities as set forth in the material provided to me in the brochure, REPRESENT that my child is in good health and proper physical condition to participate in the program, and CERTIFY that I have health and accident insurance covering any illness or injuries incurred by my child in the course of his/her participation in the program. 2. I UNDERSTAND that (a) ORCSD Summer R.E.A.C.H. Program activities can involve risks and dangers of serious body injury, permanent disability, paralysis and even death, and (b) these risks and dangers may be caused by my child’s own actions, or inactions, the actions or inactions of others participating in the program, or the negligence of the Releasees named below (#4). 3. I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I or my child may incur as a result of his/her participation in the ORCSD Summer R.E.A.C.H. Program 4. I AGREE TO RELEASE, HOLD HARMLESS, DISCHARGE, AND COVENANT NOT TO SUE ORCSD Summer R.E.A.C.H. Program, its administrators, directors, agents, officers, volunteers, and employees (Releasees) from and against all claims, demands, actions, and causes of actions for damages I or my child may have due to personal injury, death, or property damage arising from his/her participation in the program, whether or not the result of negligent acts or omissions is on part of the Releases. 5. I AGREE TO IDEMNIFY ORCSD Summer R.E.A.C.H. Program for any damage to the property of ORCSD Summer R.E.A.C.H. Program, or the property or person of other participants, caused by my child during his/her participation in the ORCSD Summer R.E.A.C.H. Program. IN THE EVENT OF AN EMERGENCY requiring medical attention beyond first aid, I hereby grant permission to physician or hospital personnel designated by the ORCSD Summer R.E.A.C.H. Program personnel to attend to my child. I have read and fully understand the above release/permission statement. By signing below, I/we understand and agree to the above, on my/our own behalf, and on behalf of my/our child. (Every parent/guardian of the child must sign.) Parent/Guardian Signature____________________________________Date:____________________ Parent/Guardian Signature____________________________________Date:____________________ Health Insurance Company___________________________________ Policy Holder:______________ Policy#______________Group#________________D#______________Certificate#_________________

© 2023 by Glorify. Proudly created with Wix.com