If you would like, or would like your child, to participate in this event use the facilities, please read, complete, sign and return this form, which includes your consent, as well as a full release of liability. As yourself, or as parent or legal guardian, you remain fully responsible for any acts of the named person during this activity.
The above child/person is eligible to participate in the above event or use the facilities in the location referenced above. The undersigned person, or the undersigned parent, guardian or legal representative, hereby consents to the participation of the person or child in the activity described and in the location where it will occur.
For and in consideration of you, or of your child being allowed to participate in the event or to use the facilities, and other valuable consideration, the undersigned, or the undersigned parent, guardian or legal representative, on behalf of the child and the child's parents, and for all their personal representatives, successors, assigns, heirs, and next of kin, does hereby release and hold harmless the Town of Groton, and its employees and agents, their personal representatives or assigns, from any loss or damage on account of any injury to the person or the personal property of yourself or of the child, as the case may be; or for death, caused by negligence or otherwise, while you or your child is engaged in the above-stated activities. The undersigned expressly agrees that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Connecticut, and that if any portion of this Agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I am aware that physical activities, games and sporting events, whether there is supervision or not, generally involve many risks, dangers and hazards including, but not limited to: overexertion, high heart rate, high blood pressure, tripping, collision, loss of balance or control, fighting, pushing, physical contact, failure to act safely or within one’s own ability or to stay within designated areas; and negligence or other acts or failures of others participants in games and other persons. I am also aware that the risks, dangers and hazards referred to above exist and that there are many other hazards that are unmarked, including those that interfere with existing medical or physical conditions resulting in bodily harm or death.
I am fully aware of my or my child’s medical condition and take full responsibility for these conditions. If I or my child has a medical condition which may cause harm or death during the activities, I will not participate or allow my child to participate.
I FREELY ACCEPT AND FULLY ASSUME ALL SUCH RISKS, DANGERS AND HAZARDS AND THE POSSIBILITY OF PERSONAL INJURY, DEATH OR PROPERTY DAMAGE OR LOSS RESULTING THEREFROM.
Parks and Recreation State License Statement:
Per Connecticut General Statute 19a-77 we are required to disclose that our programs are not licensed by the State Office of Early Childhood.
The undersigned parent, guardian, legal representative further acknowledges that he/she is authorized to enter this Agreement on behalf of the child, and the child’s parents, personal representatives, assigns, successors, heirs, and next of kin.
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