TOWN OF CHESTERFIELD
SKATEBOARD PARK

  RELEASE AND WAIVER OF LIABILITY,
ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

Please Print Participant’s Information  

First Name:                ____________                                                       

Last Name:            ____________                                                           

Home Phone:             ____________                                                        

Mailing Address:                                                             ________          

Street Address:                                                _______                        

City, State, Zip:                              _______                                          

Mother’s Name: ________                                                                       

Mother’s Work Phone:                                      Ext/Cell                ___       

Father’s Name:   ________                                                                     

Father’s Work Phone:___                                      Ext/Cell                       

Emergency Contact Name:                   __                                              

Emergency Phone (must be local):     __                     Ext/Cell     __            

Medical Issues, Allergies and/or Special Needs:

In consideration of my participation in skate park activities, I hereby agree as follows:

1.         I acknowledge that in-line skating and skateboarding involve risks which could result in physical or emotional injury, paralysis, disability, death to myself or to third parties, as well as property damage.  Some of the risks arise from the: (1) nature of the activity; (2) latent or apparent defects in or the condition of equipment or property; (3) use of property or equipment by myself or others; (4) my own acts or omissions or the acts or omissions of other participants; (5) acts or omissions of the Town; (6) my physical condition or the physical condition of others; (7) conditions of the Town facility and surrounding grounds or terrain; and (8) first aid, emergency medical treatment or emergency transportation. I accept and assume all of the risks associated with skate park activities.

2.         I hereby voluntarily release, forever discharge and covenant not to sue the Town of Chesterfields, its departments, officers, boards, employees and volunteers (“Town”) on behalf of myself, my heirs, assigns, personal representatives and estate with respect to any and all claims, liabilities, demands or causes of action which may arise in connection with my participation in skate park activities, including any claim etc. alleging negligence by the Town.

3.         I agree to abide by the Town’s Skate Park Rules and Regulations including, but not limited to, the requirement that participants wear specified safety equipment while engaged in skate park activities. I am in good health and have no medical or physical condition which could interfere with my safety in participating in skate park activities. I agree to indemnify and hold the Town of Chesterfield, its departments, officers, boards, employees, and volunteers harmless from any and all claims, demands, liabilities, damages, causes of action or lawsuits arising from my acts or omissions in participating in skate park activities at Town facilities.

I have read this entire document, understand its contents, and agree to be bound by its provisions.

                                                                                                  
Signature of Participant                                  Date

IF THE PARTICIPANT IS A MINOR (UNDER 18 YEARS OF AGE), THE PARTICIPANT’S PARENT/LEGAL GUARDIAN MUST ALSO SIGN BELOW.

I, the undersigned, state that I am the Participant’s Parent of Legal Guardian. I hereby give my consent and permission for him or her to participate in skate park activities.  I have read this Release and Waiver of Liability, Assumption of risk and Indemnity Agreement, understand its contents, and agree to be bound by its provisions.

                                                                                  Signature of Parent/Guardian                        Date