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REGISTRATION INFORMATION 89 Registration Form Parent/Guardian: First Name Last Name Birthdate Street Address Apt. # City State ZIP Day Phone Evening Phone Emergency Phone Email Participant 1: First Name Last Name Birthdate Age Grade/Grade Completed Gender Supporting the Americans with Disabilities Act, if the patron has a physical/ emotional/cognitive disability, call 702-267-4065. Activity # Activity/Class Location/Pool/Site Day/Date Time Costs NON-RESIDENTRATES | Clark County add 15% | Outside Clark County add 25% Waiver Of Liability and Disclaimer I, as the participant or parent or legal guardian of the above-named child, hereby give permission for his/her/my participation in the above-listed activity(ies). I further authorize, without prior approval, the rendering of any emergency medical treatment that may become necessary due to his/her/ my participation in the activity(ies). In consideration of the permission granted to me or the above-named child to participate in the activity(ies) listed above, I do hereby agree, on my own behalf as the participant or, if the parent or legal guardian, on my own behalf and on behalf of the above-named child, to release the City of Henderson and their officials, administrators, employees, agents, representatives, contracted instructors, and volunteers from any and all actions, causes of action, damages, claims, or demands of whatever kind or nature which I or the above named child may have against the City of Henderson or the other above-listed parties for any injuries, known or unknown, which are incurred by, arise from, or in any way relate to my or the above named child’s participation in the activity(ies) described above. The City of Henderson is not responsible for lost or stolen items. The City of Henderson reserves the right to reconcile customer balances should the customer have available credit on their account. I represent that I am the parent or legal guardian of this child or that I have permission from the child’s parent or legal guardian to enroll the child in this activity; and grant and give the City of Henderson the right to use my or my child’s photograph or image, with or without my name or the name of my child, both individually and in conjunction with other persons or objects for any and all purposes including, but not limited to, private or public presentations, advertising, publicity and promotion. I authorize the City of Henderson to share information with the Clark County School District when necessary. I have read this release and fully understand its terms. I execute the release voluntarily and with full knowledge of its significance and consequences. I understand that a copy of this waiver of liability and disclaimer will not be provided to me and I am strongly encouraged by the City of Henderson to print a hardcopy for my records. I further understand that if I am a parent or legal guardian enrolling a minor child, I will be required to submit a new registration for each school year. _______________________________________ _____________ Participant/Parent/Guardian Signature Date This form can be copied. Please print and fill out completely. Mail to: Program Registration, P. O. Box 95050 MSC 411, Henderson, NV 89009-5050 Fitness & Sports Activity Waiver Of Liability and Disclaimer Please read this carefully and be aware that by agreeing to it you will be waiving and releasing claims for potential injuries and property damage arising from participation in this fitness or sports activity. I, as the participant or parent or legal guardian of the above-named child, acknowledge that I understand the physical nature of this fitness or sports activity and that I, or the above-named child, am/is qualified, in good health, and in proper physical condition to participate in such activity. I further recognize and acknowledge that all athletic activities involving strenuous exertion or potential body contact are hazardous fitness activities and have substantial risks of injury such as transmission of diseases. I fully understand that fitness and sports classes may incorporate compound whole-body movements that demand focus and constant attention to form and may involve the risk of serious bodily injury, including, but not limited to, broken bones, torn ligaments, dislocated joints, head injury, stroke, loss of consciousness, cardiac arrest, muscle strain and sprain, back injury, joint pain, pelvic discomfort, knee or hip dislocation, punctures, abrasions, bruising, and shortness of breath which may result in permanent disability, paralysis and/or death. I understand that these and other risks may be caused by my own, or the above-named child’s actions or inaction; or by others participating in this event; by the use and adjustment of any equipment or apparatus; the conditions in which the event takes place; or the negligence of the Releasers described below; and that there may be other risks either not known by me, or the above-named child, or not foreseen at this time. I fully accept and expressly assume all such risks and responsibility for injury, losses, costs, and damages I, or the above-named child, incur as a result of my or the above-named child’s participation in the activity. I hereby release, discharge and covenant not to sue the City of Henderson, their respective administrators, directors, agents, officers, volunteers, contracted instructors and/or employees (Releasers) for occurrences of any nature or kind arising as a result of my or the above-named child’s voluntary participation in this activity. If I, or anyone on behalf of me or the above-named child, makes a claim against any of the Releasers, I or my estate will indemnify, defend, save, and hold harmless each of the Releasers from any liability, loss, damage, or cost, whether for personal injury or property damage, which they may incur as a result of such claim, except to the extent described in the next paragraph. This release, waiver of liability, and express assumption of risk agreement does not apply to any liability, claims, demands, losses, or damages arising out of the intentional, willful, or wanton misconduct of Releasers. No oral representations, statements, or inducements apart from this waiver and release have been made. I have, or will, inspect the facilities and equipment to be used in conjunction with this event and if I believe any unsafe conditions exists, I will immediately advise a class trainer of such condition and refuse to participate until such condition is corrected. I further acknowledge that I have been advised by the City of Henderson to seek the advice of a health care provider prior to my, or the above-named child’s, participation in this activity. ______________________________________________________________ _____________________ Participant/Parent/Guardian Signature Date Class 1 __ Alternate choice if unavailable __ Class 2 __ Alternate choice if unavailable __


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