Old Town Orono YMCA

Assumption of Risk, Release of Liability for Personal Injury, Medical Authorization

Participant: (Please Print) __________________________________________________Age: ________ Sex: ________

Address: ______________________________________________________________State: _______ Zip: __________

By signing this release, I acknowledge my understanding and acceptance of the following:

1. That there are numerous risks and hazards inherent in the sport of skateboarding including but not limited to: collisions with other participants and spectators. Further, I understand that there may be other risks not known to me or reasonably foreseeable at this time. I understand that having an Old Town-Orono YMCA employee present does not lessen the amount or severity of the risks of these activities. I understand that Old Town-Orono YMCA is not responsible for my safety and I freely and expressly assume and accept the responsibility for any and all risks of injury or death while participating in the sport of skateboarding,.

2. I acknowledge I have been given the opportunity and have been encouraged by Old Town-Orono YMCA to inspect the ramps, facilities and courses PRIOR to signing this release and continuously while using the facilities. Initials: ___________

3. I hereby assume any and all risks of property damage, personal injury or death arising from my participation in the sports of skateboarding, or while present on the Old Town/Orono YMCA premises, and I agree to RELEASE, FOREVER DISCHARGE, INDEMNIFY, DEFEND and HOLD HARMLESS the Old Town-Orono YMCA, its directors, officers, agents, employees, as well as the equipment manufacturers and distributors, hereafter Releasees from any and all losses, damages, costs and attorney’s fees resulting from any and all claims or suits for personal injury, death and/or property damage that may in any way arise out of my participation in this activity, related activities, or my use of the facility, its equipment, or any equipment, regardless of how or by whom or by what the personal injury, death and/or property damage was caused.

4. I AGREE TO RELEASE, FOREVER DISCHARGE, INDEMNIFY, DEFEND, AND HOLD HARMLESS THE RELEASEES FROM ANY AND ALL CLAIMS, SUITS, COSTS AND ATTORNEYS FEES FOR DAMAGE AND PERSONAL INJURY TO ME OR MY PROPERTY RESULTING FROM THE NEGLIGENT ACTS OR OMISSIONS OF THE RELEASEES. I UNDERSTAND THAT THE RELEASEES ARE NOT RESPONSIBLE FOR THE CONSEQUENCES OF THEIR OWN NEGLIGENCE, THAT IS, THEIR FAILURE TO USE REASONABLE CARE IN ANY WAY.

5. I understand that this agreement shall be binding upon my heirs, executors, administrators, and assigns and shall be governed by the applicable law of Maine. I also understand that if any part of this agreement is determined to be unenforceable, all other parts shall be given full force and effect. I agree that any claims that I may bring against the Releasees shall be submitted to the jurisdiction of the state or federal Courts in Maine and that no claims against the Releasees shall be brought in any other jurisdiction. I agree that there have been no warranties, expressed or implied, which have been made to me, which extend beyond the description of the equipment listed on this form.

6. I give permission for Old Town/Orono YMCA staff to administer first aid in cases of minor injuries, and in cases of sever injury until trained medical personnel can be reached. I authorize Old Town/Orono YMCA staff to give permission for emergency medical treatment if reasonable effort to contact parent/guardian has failed, and qualified medical personnel consider treatment necessary. Additionally, I hereby agree to individually provide for all possible future medical expenses, which may be incurred by my child as a result of any injury, sustained while participating at the Old Town/Orono YMCA.

I have read the Release of Liability for Personal Injury and have been given the opportunity to speak with a representative of the OLD TOWN/ORONO YMCA before signing this release.

Signature (Participant): ________________________________________________________Date: ____/_____/_____

As parent/guardian signing this agreement for the above named minor, I acknowledge and agree that I have read the above document, and that by signing this document on behalf of the minor, the minor and I agree to be bound by its terms. I hereby agree to INDEMNIFY, DEFEND and HOLD HARMLESS the Releasees for any claim or suit arising out of said minor’s participation in the activity or said minor’s presence on Releasee’ premises.

Signature of Parent or Guardian: _____________________________________________

Print Full name: _____________________________________________ Phone: ____________________

Emergency Contact: _________________________________________ Phone: ____________________

Date: ___________/__________/___________

For YMCA promotional use only, I give my permission to have photos/videos taken of the above named minor:

_____YES _____NO __________Initials