Pottstown and Upper Perkiomen Valley YMCA Skate Park Application and Liability Waiver Skater Information (please print): Name_______________________________________________________________________________________________________ Date of Birth____________________ Address_____________________________________________________________________________________________________ City______________________________________State__________Zip Code______________ Home Phone_________________________ Work Phone_________________________ Cell Phone_________________________ Mother’s Maiden Name________________________________________________________________________ Emergency Information: Name ______________________________________________________________________________Relationship_______________ Home Phone_________________________ Work Phone_________________________ Cell Phone_________________________ LIABILITY WAIVER AND HOLD HARMLESS ARGREEMENT READ BEFORE SIGNING I recognize that this Liability Waiver bars my right to sue or to recover damages for any injury or property loss I sustain at the Skate Park. I fully understand that use of the Skate Park is dangerous and involves the risk of serious bodily injury and other losses. In applying to enter the YMCA Skate Park, I promise to inspect the site and reassure myself that the area, ramps and weather conditions are safe for skating. If they are not, I will notify the person in charge and will not use the Skate Park. I voluntarily agree to assume the risk and accept personal responsibility for any and all injuries and/or damages I sustain at the Skate Park. In consideration of your acceptance of this application, I, intending to be legally bound hereby, for myself, my heirs, my executors and administrators, hold harmless, release and forever discharge the above named YMCAs, their administrators, officers, directors, agents, employees, other participants, sponsoring agencies, sponsors and advertisers, of and from any and all liability whatsoever, including injury or damages resulting from my or anyone else’s negligence, arising from my presence or participation at the Skate Park. I attest that I am physically fit and have sufficient training and experience for this activity. I also waive and release the use of my photograph or likeness for any reason or purpose. I have read, understand and promise to abide by all of the Skate Park admission requirements, rules and regulations. I HAVE READ THE ABOVE LIABILITY WAIVER AND HOLD HARMLESS AGREEMENT, AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT VOLUNTARILY Skate Park User’s Signature __________________________________________________Date_______________________________ Note: If under 18 years old, parent or guardian must sign below in the presence of service desk staff or skate park attendant, or must have his/her signature notarized. Parent’s Liability Waiver and Medical Release: I hereby certify that I am the parent or guardian of the skater named above. I have read, understand and agree to the above Liability Waiver and Hold Harmless Agreement, and I consent to the above named child’s use of the Skate Park on said terms. I further agree to hold harmless the Pottstown and Upper Perkiomen Valley YMCAs from any and all liability for any and all injuries and/or damages to the above named child. I certify that I am authorized to make this liability waiver and hold harmless agreement. In the event I cannot be reached in an emergency, I hereby give permission to any licensed physician, surgeon, clinic or hospital to administer all necessary and proper treatment for the child named above. I state that the child is free from all communicable diseases and has not been treated for any such disease within the past six months, and has received all required immunizations. I hereby certify that I am authorized to give this permission for medical treatment for the above named child. Parent or Guardian’s Signature __________________________________________________Date_______________________________ Note: Hold Harmless and Medical Release form MUST be signed to enter park.