RAD - Parent/Guardian Form & Waiver

Please complete all of the following information for the program participant. This form must be completed by the participant’s parent or legal guardian and should not be completed by the program participant.

Parent/Guardian Name(Required)

First Last

Parent/Guardian Gender(Required)

Parent/Guardian Date of Birth(Required)

Active Duty Military or Veteran(Required)

Parent/Guardian Email(Required)

Enter Email Confirm Email

Parent/Guardian Phone Number(Required)

Country Phone Number

Emergency Contact(Required)

First Last

Emergency Contact cannot be the same as the parent/guardian named above.

Emergency Contact Phone Number(Required)

Country Phone Number

Parent/Guardian Address(Required)

Street Address Address Line 2 City ZIP Code

Participant Information

Please complete the following for the program participant.

Participant Name(Required)

First Last

Participant Gender(Required)

Participant Date of Birth(Required)

Participant Email Address(Required)

Participant Phone Number(Required)

Participant Address

Street Address Address Line 2 City State ZIP Code

Please enter the participant’s home address if it is different from the address listed above.

Participant Medical and/or Allergy Information(Required)

Please list any medical needs, allergies, or other health-related information that YMCA staff should be aware of to help ensure the participant’s safety and well-being. If none, please type N/A.

YMCA of the Pikes Peak Region, Acknowledgment and Assumption of Risk

1. Acknowledgment of Risk I understand that participation in activities at the YMCA—including personal training, strength training, cardiovascular exercise, group fitness classes, youth programs, aquatics, and use of facilities such as locker rooms, saunas, and steam rooms—involves inherent risks, including risks arising from instruction, supervision, training, or guidance provided by YMCA staff. These risks include, but aren’t limited to; slips and falls, equipment malfunction, improper use of equipment, overexertion, muscle strains, sprains, abnormal blood pressure, heart-related conditions, dehydration, dizziness, fainting, serious injury, illness, exposure to communicable diseases, or death. I knowingly and voluntarily assume all risks, including but not limited to claims arising from the negligence of the YMCA, its officers, directors, employees, agents, and volunteers. 2. Medical Acknowledgment I am responsible for determining my physical fitness and medical ability to participate. I have either consulted a healthcare provider or chosen to participate without such consultation. I agree to stop if I experience any symptoms or concerns. THE UNDERSIGNED further expressly agrees that the foregoing Acknowledgement of Risk is intended to be as broad and inclusive as is permitted by the law of the State of Colorado and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND Acknowledgement of Risk, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT IN CONSIDERATION of being permitted to utilize the facilities, services and programs of the YMCA for any purpose, including, but not limited to observation or use of facilities, or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, inspected and carefully considered, or will immediately upon entering and/or participating, inspect and carefully consider, such premises and facilities or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: 1. Release of Liability THE UNDERSIGNED ON HIS OR HER BEHALF AND/OR BEHALF OF HIS/HER CHILDREN (hereinafter referred to as “the undersigned”) HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, and agents (hereinafter referred to as “releasees”) from all liability to the undersigned, his or her personal representatives, assignees, heirs, and next of kin for any loss or damages, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releasees or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA. 2. Indemnification THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in, upon or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releasees or otherwise. 3. Participant Responsibilities and Conduct THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of releasees or otherwise while in about or upon the premises of the YMCA and/or while using the premises, or any facilities or equipment thereon or participating in any program affiliated with the YMCA. The undersigned further agrees to follow all YMCA rules and policies, use equipment properly, follow staff instructions and posted signage, and report any unsafe conditions. I agree to abide by all rules and regulations of the YMCA of The Pikes Peak Region, and I understand that failure to act in accordance with the rules may result in expulsion from the YMCA and cancellation of membership. 4. Minor Participant Waiver (if applicable) I, as parent or legal guardian, knowingly and voluntarily assume all risks on behalf of the minor and agree to release, waive, and indemnify the YMCA from any claims brought by or on behalf of the minor. 5. Personal Property I understand that the YMCA is not responsible for personal property lost, damaged or stolen while using YMCA facilities or participating in YMCA programs. 6. Insurance The YMCA does not provide insurance coverage. I am responsible for my own including medical, accident, and liability coverage. 7. Medical Authorization I authorize the YMCA, as my agent, to give consent to medical treatment by a licensed physician, hospital, or first responder, when such treatment is deemed necessary by the medical professional, and I am unable to give such consent. I authorize a qualified YMCA staff member to administer CPR or first aid if necessary. I understand that it may be necessary for me to provide a release form from my physician regarding my current health status. 8. Photo and Media Release I hereby irrevocably release, consent and allow the YMCA of The Pikes Peak Region and its agents to use my photograph/likeness/voice, as it pertains to my participation with the YMCA, in any manner for promotional efforts without expectation of any reimbursement for its use compensation, in any media now known or later developed, in perpetuity. 9. Governing Law and Venue This agreement is governed by Colorado law and any disputes shall be resolved in Colorado courts. 10. Severability If any provision is invalid, the remainder remains in effect.

Signature(Required)

YMCA of the Pikes Peak Region

RAD - Parent/Guardian Form & Waiver