PARTICIPANT RELEASE STATEMENTYou recognize and understand the activity that your family has enrolled in, and hereby give your permission and consent for their participation. The undersigned acknowledges and accepts the level of care, equipment, facilities, and supervision which will be provided and recognize that inherent to the activity is an assumptionof risk. You, for yourself and as appropriate on behalf of your child, do hereby absolve, release and agree to hold harmless the Recreation Center and the City of Cedar Falls, its employees, sponsors, leaders, agents, and volunteers (hereinafter “Releasees”) from liability claims in case of accidents to all family membersenrolled in these programs. This release waives all claims whatsoever, known or unknown, which may arise by virtue of participation in the activity, including injury or death to self or child, and damage to property, however such claim may arise, including but not limited to breaches of duty (such as breach of the duty of care) and acts of current or future negligence by the Releasees. This release waives any claims whatsoever against the Releasees arising from the actions of any other participant in the activity or any other third party. Further, this release covers all activities immediately before and after participation, including transportation to or from the event, and waiting for rides from City or other facilities after the event. The undersigned further agrees to defend and hold harmless Releasees, their respective officers, employees, or agents against any claim, cause, loss, or damage whatsoever, including attorney fees, that arises from the above-described activity. This release is specifically intended to indemnify the Releasees from any act of negligence of the undersigned. Participation involves a risk of injury. By signing this form, you represent that you have considered the risks of participation in the activity, have obtained any medical clearance necessary to participate, and your child is able to participate without harm to self or others. You represent that any program equipment will be used with care for yourself, other participants and your surroundings. PHOTO RELEASE STATEMENTParents or others may take audio or video recordings of the participants. The City does not supervise or restrict recordings of public activities by third parties. We grant permission of videos and pictures of family members to be used in publicity or promotion related to the City of Cedar Falls Human and Leisure Services Department.TRAVEL AUTHORIZATIONThe undersigned gives permission for child to leave the program site with the Camp Cedar Falls program, for activity or field trips by city van, school bus, or by foot. The undersigned understands that a handout and/or special event flyer will be provided before field trips. The undersigned must complete and return a separateconsent form for off-site travel trips.RULES OF CONDUCTThe undersigned agrees that all rules of conduct established in conjunction with the activity shall be followed. Failure to follow the rules will result in removal from the activity and any program fees paid will be kept by the City and not refunded. In the event of a problem while engaged in the activity, the undersigned agrees to notifythe activity manager/supervisor. This Release is given in partial consideration of your being allowed to participate in the activity described, and binds yourself, your personal representatives, and any heirs or assigns.LIMITED POWER OF ATTORNEY FOR EMERGENCY MEDICAL CARE AUTHORIZATIONI, the undersigned, being the parent or legal guardian of said minor child, know that I may not be available to authorize medical, dental, surgical care and hospitalization for said minor child. In the event of injury, program supervisors shall administer basic first aid, and shall summon emergency services via 911. Supervisors are not trained to provide detailed medical care, and shall not, without prior agreement, provide medications. All costs of emergency care are the responsibility of the participant/participant’s legal guardian(s). NO INSURANCE IS PROVIDED BY THE CITY FOR INJURY TO PARTICIPANTS. All claims for reimbursement of medical care costs, including emergency transportation, are hereby waived.I HAVE READ THIS DOCUMENT CAREFULLY AND UNDERSTAND IT.I AM SIGNING THIS FREELY AND WITHOUT RESERVATION OR CONDITION.(IF YOU HAVE ANY QUESTIONS ABOUT THIS DOCUMENT DO NOT SIGN IT. CONTACT AN ATTORNEY TO ASSIST YOU.)
Health Insurance Carrier * Policy Number *
H:WorkRisk ManagementRELEASESRevised 2010Release and Medical Authorization.Rec Center Programs.2010.doc
I (Parent/Guardian) blankgive consent to the City of Cedar Falls to hold my child’s medication for this Recreation Division Program. The medication must be in the original container and contain no more than a 5-day supply. I understand that the Cedar Falls Recreation Division will hold them before & after the child is to take it. It is not the responsibility of the Cedar Falls Recreation Division to make sure my child has received the proper dosage. If a pill is to be taken as a half, the pills must be cut in half by the parent.The following medication has been received from (Parent/guardian) for use by my child (child's name) blank.