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Assumption of Risk and Release Form - Draper Parks and Recreation
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Email (All addresses kept under strict confidentiality)
Month and Year of Birth (Example 10/2006)
This form will be submitted for the following event:
It's My Park: Volunteer (April 24, 2021 at Historic Park)
Emergency Contact Name
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I, the undersigned, being at least eighteen (18) years of age, or if I am under 18 years of age my parent and/or guardian will sign on my behalf, desire to participate as a volunteer in work relating to or sponsored in part by Draper City. In consideration of acceptance, approval and participation in the work project (the “Project”), I hereby enter into this Informed Consent, Waiver and Release Agreement with Draper City (hereinafter the “City”).
I recognize that the Project will involve physical labor and carries a risk of personal injury and/or physical and emotional discomfort. I hereby acknowledge that I am free from any known heart or other serious health problems that could prevent me from participating in any of the activities associated with the Project. I further acknowledge and represent that I am sufficiently physically fit to participate in the activities of the Project.
I recognize that there are natural and man-made hazards, environmental conditions, diseases and other risks which, in combination with my actions, may cause injury to me. I hereby agree to assume all risks which may be associated with or may result from my participation in the Project, including, but not limited to, transportation to and from volunteer sites. Injuries to participants in Draper City programs may occur from risks inherent in the sports or activities; from placing stress on the body that it has not been prepared for; from accidents in learning or practicing techniques; from failing to follow training, safety or racing rules; from the use of transportation and from administration of first aid. The severity of the injury can range from minor cuts, scrapes, or muscle strains to catastrophic injury such as paralysis or even death. I will be exposed to the weather, including rain, wind, cold, and sun, I might become ill through chill or suffer sunburn and heat exhaustion. In order to avoid injuries I will obey the directions of my instructors and will follow all safety rules. I will tell my instructor about any limitations or medical restrictions on my participation.
I recognize that if I am accepted for the Project, I will be considered a volunteer of Draper City and not an employee. I hereby agree to accept supervision as directed by the City and to perform my volunteer services to the best of my ability and in a professional manner. As a volunteer, I understand that I may be considered a government employee under the Utah Volunteer Government Workers Act for the limited purposes of: (1) receiving workers’ compensation medical benefits; (2) the operation of a vehicle or equipment if I am properly licensed and authorized to operate said vehicle or equipment; and (3) liability protection and indemnification normally afforded paid government employees. I understand that workers’ compensation medical benefits shall be my exclusive remedy for all injuries incurred while acting as a volunteer for the City and I hereby certify that I will be personally responsible for the cost of any emergency or other medical care that I receive which is not covered under said workers’ compensation medical benefits. In the event of an injury, I hereby expressly consent to any emergency medical aid, anesthesia, and/or operation, if in the opinion of the attending physician, such treatment is reasonable and necessary.
I authorize Draper City the right to take , publish, and make use of any and all pictures or video taken of me to be used in and/or for promotional materials including, but not limited to, newsletters, flyers, posters, brochures, annual reports, websites and social networking sites and other print and digital communications, without payment or any other consideration. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing.
I hereby waive and release any and all claims I have or may have in the future against the City, its officers, agents, employees, assigns, and sureties, for any liability, damage, claim, injury, loss, expense, attorney fees, or harm of any kind whatsoever arising out of my participation in the Project.
I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND UNDERSTAND THE CONTENTS OF THIS AGREEMENT AND THAT IF I AM 18 YEARS OR OLDER I SIGN THE SAME OF MY OWN FREE WILL. IF I AM UNDER 18 YEARS OLD, MY PARENT OR GUARDIAN AGREES TO AND SIGNS THIS AGREEMENT. I FURTHER ACKNOWLEDGE THAT THIS AGREEMENT SHALL BE BINDING UPON MY HEIRS, REPRESENTATIVES AND ASSIGNS.
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Parent or Guardian signature required for participants under the age of 18.
Signature of Guardian (required if volunteer is under 18)
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