party release form.indd

Mason Community Center
6050 Mason-Montgomery Road
Mason, Ohio 45040
513.229.8555
GUEST INFORMATION
RELEASE OF ALL CLAIMS
PLEASE PRINT
______________________________________________________________________________________________________________________________________________________________________________________________________
Last Name
First Name
Middle Initial
Date of Birth
______________________________________________________________________________________________________________________________________________________________________________________________________
Street Address
City/St
Zip Code
(________) __________________________________________ (________) ___________________________________ (________) ___________________________________(________) ________________________________________
Home Phone
Work Phone
Cell Phone
Emergency Phone
_______________________________________________________________________________________________________________________________________________________________________________________________________
E-mail
_______________________________________________________________________________________________________________________________________________________________________________________________________
Emergency Contact Name
Relationship
(________) _______________________________________________________________________________________ (________) _______________________________________________________________________________________
Phone Number
Alternate Phone Number
Release of All Claims and Agreement Not to Sue
As additional consideration of my application and permitting me the opportunity to participate in recreational activities and to
utilize the facilities at the Mason Community Center, the undersigned hereby waives, releases, discharges, saves, holds harmless, and indemnifies the City of Mason and the Mason City School District, their employees, volunteers, agents, and independent contractors, from any and all claims of whatever kind, to me, my spouse, or my dependents which may directly or indirectly arise. I hereby agree to accept any and all risk of personal injury, illness, death, or property damage and verify this statement
by placing my signature below. Furthermore, by signing below for myself, my dependents, and/or my spouse, I understand this
release bars claims by the undersigned’s spouse, dependents, heirs, assigns, executors, and administrators.
I understand that photographs and/or videotapes of me and my family members may be taken for use in promoting the City of
Mason activities and facilities in future editions of CenterPoint, in a variety of other publications, on display boards throughout
the Community Center and for other uses by the City of Mason. I hereby give my permission to use such photographs without
compensation to me.
I HEREBY CERTIFY THAT I HAVE CAREFULLY READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM
AWARE THAT THIS IS A RELEASE OF LIABILITY AND A LEGAL CONTRACT AND THAT IT AFFECTS MY LEGAL RIGHTS. I
AM SIGNING THIS DOCUMENT OF MY OWN FREE WILL.
_______________________________________________________________________________________________________________________________________________________________________________________________________
Signature of Applicant
Date
_______________________________________________________________________________________________________________________________________________________________________________________________________
Parent/Guardian signature of any dependent under 18 years old
Date