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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State
9. Zip Code
11. Email Address*
12. Phone Number
16. RECREATION WAIVER AND RELEASE STATEMENT *
    -- Select One --I agree

    In consideration of being allowed to participate in the above-mentioned Adult Athletic League, I hereby, for myself, my child, our heirs, executors and assigns, acknowledge, appreciate and agree:

    1. Waiver Statement: I hereby release, absolve and hold harmless the City of Lakeville, its officers, employees and agents from damage resulting from any injury incurred by me or my child while participating in the above-mentioned programs. I/we understand that the City of Lakeville assumes no responsibility for injury before, during or after programs. This waiver of liability does not waive liability for any injuries that I obtain as the result of willful, wanton or intentional misconduct by the City or any person acting on behalf of the City. 

    2. Photos: Lakeville Parks & Recreation Department periodically takes pictures of participants in our programs, during special events and in the parks. These photos may be used in the City’s media publications. Participation in a recreation activity serves as your consent to such photographs and recordings unless you indicate otherwise to the department staff. If you do not wish to have your image used, notify us in advance in writing.

18. Signature*

    Checking the box below will serve as your electronic signature.

    1. Signature
20. Date
    Date
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22. 1. Receive an email copy of this form.
23. Email address

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24. Submit

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