• Name

  • If under age 18, Parent or Guardian MUST sign in the signature block at the bottom of the form
  • Emergency Contact Info

  • Waiver

  • I realize that participating in any physical activity is physically demanding and potentially hazardous. I agree to abide by any decision of the event organizer relative to my ability to participate. I assume all risks associated with my participation in the physical activities while on the premises of the Poplar Heights Recreation Association (PHRA), which risks may include, but are not limited to, contact with other participants, falls, personal injuries, sickness, death, disability, damage to tangible or intangible personal property, as well as the effects of weather and traffic. I have read this waiver and, knowing these facts and in consideration of my election to participate in this event, I, for myself, my minor children, if applicable, and anyone entitled to act on my behalf, waive and release PHRA and its directors, officers, agents, contractors, volunteers and sponsors (collectively, the “Releasees”) and will indemnify, defend and hold Releasees harmless from all claims and liabilities of any kind, including any claims by third parties, arising out of my participation in this activity. I acknowledge that I am at least 18 years old, and am voluntarily participating in such events. If my/our minor child participates in the activity, I acknowledge and assume all risks associated with their participation in this activity.

  • (If under age 18, Parent or Guardian MUST sign below)