City of Fort Myers S.T.A.R.S.

Authorizations- Please read carefully

Participation

• I give permission for my child to participate in all activities, including field trips and swimming, and to be transported as authorized by the City of Fort Myers S.T.A.R.S. Division.
• I give permission for the City of Fort Myers S.T.A.R.S. Division to use any pictures of my child for future promotional purposes.

Medical Treatment

I hereby give permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a qualified staff member of the City of Fort Myers S.T.A.R.S. Division in the event of emergency, I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical and hospital care treatment and procedures (including, but not limited to, administration of necessary anesthetics, tests, x-ray examinations, transfusions, injections, drugs) to be performed for my child by a licensed physician or hospital selected by the City of Fort Myers S.T.A.R.S. Division Manager when deemed immediately necessary or advisable by the physician to safeguard my child’s health.

Release from Liability

Assumption of the Risk and Waiver of Liability

Coronavirus/COVID-19

Photo Release

(Read Carefully Before Signing)

 

Release from Liability

As a participant in activities/programs/ other with the City of Fort Myers S.T.A.R.S., Recreation or Recreation Partner, I acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries including loss of life, damages or loss which my child may sustain because of participating in any and all activities connected with or associated with such program. I agree to waive and relinquish all claims, fully release and discharge and agree to indemnify and hold harmless and defend the City and its officers, agents, and servants and employees from any and all claims resulting from injuries, including loss of life, damages and losses sustained by me arising out of, connected with, or in any way associated with the activities of the program

 

In Regards to the Coronavirus

The novel coronavirus, Coronavirus/COVID-19, has been declared a worldwide pandemic by the World Health

Organization. Coronavirus/COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. Federal authorities and the State of Florida recommend social distancing to prevent the spread of Coronavirus/COVID-19. Contracting Coronavirus/COVID-19 can lead to severe illness, personal injury, permanent disability, and death. The City of Fort Myers S.T.A.R.S and/or Recreation Programs and staff undertake every effort to keep our facilities clean and disinfected and have created new protocols and preventative measures to reduce the spread of Coronavirus/COVID-19; however as with any public facility, the City cannot guarantee that you or your minor child(ren) will be 100% safe from airborne illnesses such as Coronavirus/COVID-19 or colds and flu while using City of Fort Myers S.T.A.R.S. and Recreation facilities or participating in its programs.

 

By signing this agreement I acknowledge the contagious nature of Coronavirus/COVID-19 and voluntarily assume the risk that my minor child(ren) and I may be exposed to, or infected by COVID-19 while using City of Fort Myers S.T.A.R.S and Recreation facilities or participating in its programs, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by Coronavirus/COVID-19 at or while using City of Fort Myers S.T.A.R.S. and Recreation facilities, or participating in its programs may result from the actions, omissions, or negligence of myself and others, including, but not limited to, City of Fort Myers employees, volunteers, program participants and their families.

 

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my minor child(ren) or myself including, but not limited to, personal injury, disability, death, illness, damage, loss, claim, liability, or expense, of any kind, that I or my minor child(ren) may experience or incur in connection with use of City of Fort Myers S.T.A.R.S and Recreation facilities, and/or while participating in its programs. On my behalf, and on behalf of my minor child(ren)s, I hereby release, covenant not to sue, discharge, and hold harmless the City of Fort Myers, its officers, employees, agents, and representatives, of and from any and all Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the City of Fort Myers, its officers, employees, agents, and representatives, whether a Coronavirus/COVID-19 infection occurs before, during, or after participation in any the City of Fort Myers S.T.A.R.S. and Recreation Department program or the use of its facilities. Nothing herein shall be construed to waive or alter the City’s sovereign immunity or the limits, rights, or requirements of Section 768.28, Florida Statutes.

 

By signing my name below I certify that: (1) I am the Parent/Guardian of the Child participant(s) listed on this

Registration Agreement or I am an adult participant over 18 years of age; (2) I have fully read and understand the above terms and conditions and they apply to Child participant(s) or myself; (3) I understand that I am waiving important legal rights to recover damages for injury and/or property damage; (4) I agree I have been encouraged to seek the advice of my own attorney prior to signing this agreement; (5) I have read and voluntarily signed this agreement; and (6) no oral representations, statements or inducements apart from the foregoing written agreement have been made.

 

Photo Release:

The applicant hereby gives permission for the City of Fort Myers S.T.A.R.S or other City Departments/Divisions use, without limitation or obligation, photographs or other media that may include the members’ image or voice to promote or interpret City of Fort Myers S.T.A.R.S. Divisional programs.

 

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

THE STAFF AT THE City of Fort Myers S.T.A.R.S. Division IS VERY CONCERNED WITH THE WELFARE OF OUR CHILDREN. WE NEED YOUR HELP IN INFORMING US OF ANY ILLNESS OR SPECIAL NEEDS THAT YOUR CHILD WILL HAVE. City of Fort Myers S.T.A.R.S. STAFF DOES NOT ADMINISTER MEDICATIONS OF ANY KIND. Please check any of the following medical conditions that may apply to your child.

I, {primaryParent}____________ the parent/ guardian of the above named student recognizes that as a result of participation in activities, medical treatment in an emergency may be necessary and further recognize that the S.T.A.R.S. personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under then existing circumstances. Please make notation of my son/ daughter’s records below.

PLEASE NOTE: Additional registration process may be required for some activities.  Parents will be contacted by team representative with further instructions

Please call (239) 321-7545 ext# 5 with any questions

• All Activities have a non-refundable administrative fee of $15.00
• There are no refunds for of any kind once the program begins