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PROGRAM / ACTIVITY REGISTRATION / WAIVER
PROGRAM/ACTIVITY WAIVER_________________________________________________________________ NAME_______________________________________________________________________________ ADDRESS ___________________________________________________________________________ CITY_______________________________ STATE___________________________________________ PHONE (H) ___________________________________________________________________________ PHONE (W) ___________________________________________________________________________ CELL #_______________________________________________________________________________ E-MAIL ADDRESS ______________________________________________________________________ EMERGENCY CONTACT___________________________________PHONE______________________________ WAIVER OF CLAIMS AND RELEASE FROM LIABILITY I RELEASE, ABSOLVE AND AGREE TO HOLD HARMLESS AND INDEMNIFY The City of New Iberia and its Parks and Recreation Department, their staff, sponsors and representatives from and against any and all liability, and from and against any claims, demands, costs or expenses, or causes of action arising out of or in connection with the above program/activity for which I have registered myself or my child. I expressly acknowledge that I am aware that the above program/activity, even under the safest of condition possible, may involve risk to me. Nevertheless, I expressly assume all risk or hazard related or coincidental to, arising out of or connected to, the above program/activity, including risk of loss or damage to property and/or personal injury or death, however caused. If I have any questions or concerns, or I feel I do not have adequate information about risks or hazard of the above program/activity, I realize that I should not sign this Waiver and Release before satisfying myself completely about such question or concern. I represent to the City of New Iberia, and Parks and Recreation Department, knowing that it will rely on my representation, that I have the experience, training, and knowledge appropriate to participate in the above program/activity without supervision or special precautions. I also represent that I do not have any special needs or require special accommodation necessary for me to participate safely in the above program/activity. If I do, however, have special needs or require special accommodation, then I have disclosed them to the appropriate staff person of the City of New Iberia Parks & Recreation Department. I realize and agree that the City of New Iberia Parks & Recreation Department may decline to allow me to register for the above program/activity due to such special needs or required special accommodation. I further represent that I am physically fit to participate in the above program/activity and have not otherwise been informed or cautioned to restrict my physical activities by a physician. I am of legal age and competent to sign this Waiver and Release. I REALIZE THAT I AM GIVING UP LEGAL RIGHTS AGAINST THE CITY OF NEW IBERIA AND ITS PARKS & RECREATION DEPARTMENT BY SIGNING THIS. I HAVE READ THIS WAIVER AND RELEASE FULLY AND UNDERSTAND ALL ITS PROVISIONS. I give my permission and grant to the City of New Iberia and its Parks & Recreation Department the right to make pictures and sound recordings of me or my child and the right to use such pictures and sound recordings, including the right to identify my child's name, likeness, voice and words, in television, film, newspaper, magazine, internet, and other media of any form, for the purpose of advertising and communicating the objectives of programs and activities offered by the City of New Iberia's Parks and Recreation Department and for the purpose of applying for funds to support those purposes and activities.
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