C.A.E. Activity Waiver & Liability Release

C.A.E. Complex Activity Waiver

Once submitted, you will receive a confirmation of receipt by email. For questions or more information, please call Ms. Traci Gregory at (866) 961-2239 extension 7.
Name of Participant

First NameLast NameSuffix
Is the participant an MCHA Resident?
Is the participant age 17 or younger?*
Date of Birth*

MonthDayYear
Date
What is participants gender?*
Primary Parent/Guardian Contact (Only if participant is under the age of 18 years)

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
ACTIVITY OR EVENT INFORMATION
Name of Event/Activity*

OPEN GYM PRICING

Youth ages 7-17 ................................................................................... FREE

Adults 18 and over ........................................... $5 per day or $25 per month

Family (including two adult members per household) .................. $30 per month

Family (including 3 to 5 adult members per household) ............... $50 per month

*All MCHA residents receive a 50% discount

*Scholarships are made available upon request and eligibility

You may pay at the CAE Complex (Chavers Center) or online

via Cash App at $CAEWORLDWIDE
MEDICAL HISTORY

If the participant is a minor 17 years of age or younger, this section must be completed by the participant's parent/guardian.
MEDICAL RELEASE: I authorize C.A.E. to arrange for transportation in case of an accident or acute illness of the participant. If it is impossible to receive instruction for the participant’s care, consent is given to any licensed physician for treatment. I allow the physician to administer medication and perform the necessary treatment to preserve the participant’s health and well-being. I understand that I shall pay any cost incurred to treat sudden illness or accident. This authorization and consent for treatment are given to C.A.E. in conjunction with any authorized event.
Does your child have any serious illness? (I.e. severe asthma, heart disease, diabetes, depression)?
If yes, what serious illness does your child have?
Does your child have any serious or life threatening allergies, including food allergies, (i.e. bee stings, peanuts,dairy, allergies to medications)?
If yes, what life threatening allergies does your child have?
EMERGENCY CONTACTS

In case of emergency, please notify:*

Rows	Name	Phone	Relationship
Contact 1
Contact 2

RELEASE & WAIVER OF LIABILITY
This Release and Waiver of Liability (the “release”) executed Date by     First Name   Last Name   (“Participant”) releases Community Arts Experience, Inc. (C.A.E.), (“Nonprofit”), a nonprofit corporation organized and existing under the laws of the State of Pennsylvania and each of its directors, officers, employees, volunteers, project collaborators, and agents. The Participant desires to engage in activities provided by the Nonprofit.

1.    Waiver and Release: I hereby release and forever discharge and hold harmless Nonprofit and its successors and assigns from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arises or may hereafter arise from the services I provide to Nonprofit. I understand and acknowledge that this Release discharges Nonprofit from any liability or claim I may have against Nonprofit concerning bodily injury, personal injury, illness, death, or property damage that may result from activities provided by Nonprofit or occurring while I am providing Participant services if applicable.

2.    Insurance: Further, I understand that Nonprofit does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance. I expressly waive any such claim for compensation or liability on the part of the Nonprofit and each of its directors, officers, employees, volunteers, project collaborators, and agents beyond what may be offered freely by the Nonprofit in the event of injury or medical expenses incurred by me.

3.    Medical Treatment: I hereby release and forever discharge Nonprofit from any claim
whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my tenure as a Participant with Nonprofit.

4.    Assumption of Risk: I understand as a Participant, I hereby expressly assume the risk of injury or harm from activities associated with the Nonprofit and Release Nonprofit and each of its directors, officers, employees, volunteers, project collaborators, and agents from all liability.

5.    Photographic Release: I grant and convey to Nonprofit all rights, titles, and interests in any and all photographs, images, videos, or audio recordings of me or my likeness or voice made by Nonprofit in connection with my activities provided by Nonprofit.

6.    Other: As a Participant, I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Pennsylvania and that this Release shall be governed by and interpreted in accordance with the laws of the State of Pennsylvania. I agree that if any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected.
ATTESTATION
By signing below, I express my understanding and intent to enter into this Release and Waiver of Liability willingly and voluntarily.
- I certify that the information is true and correct to the best of my knowledge.
- I understand that all information contained herein will be held in strict confidence by C.A.E. and will not be released to any outside party without the applicant’s consent.
e-Signature*

Clear
The electronic signature, whether digital or encrypted, is intended to authenticate this document and to have the same force and effect as a manual signature.
Printed name of individual that signed above*
Should be Empty:

C.A.E. Complex Activity Waiver

RELEASE & WAIVER OF LIABILITY