Hold, Harmless & Medical Release Form

The Wheelhouse Skate Center
Membership Registration
HOLD, HARMLESS & MEDICAL RELEASE FORM

For Office Use Only

Initial:_______________________
ID Verification
Drivers Lic.#_________________

HOLD HARMLESS FORM This release limits your right to recover damages in case of an accident. READ THIS BEFORE SIGNING In applying to enter the WHEELHOUSE SKATE PARK, I promise to inspect the park site, and assure myself that the area and conditions are safe for skating purposes. I will further read and comply with all WHEELHOUSE rules and regulations note existing weather conditions and voluntarily agree assume all risks arising from conditions related to use of the skate site by others and myself. In consideration of your acceptance of my entry, I, intending to be legally bound, hereby, for myself, me heirs, executors and their members, agents and any other officials whatsoever arising from my presence or participation in the Skate Park. I attest that I am physically fit and sufficiently trained for this activity, and do hearby grant the sponsors such release as described herein. I also waive and release the use of my photograph or likeness for any reason or purpose. I acknowledge that I have read and understand the above.
_________________________________________ SKATE PARK USER'S SIGNATURE	_________________________________________ DATE
SKATE PARK USER'S PARENTS SIGNATURE I hearby certify that I am the parent or guardian, of the skater named above, and do give my consent without reservations to the foregoing and agree to hold harmless the aforementioned from any liability
_________________________________________ PARENT OR GUARDIAN SIGNATURE	_________________________________________ DATE
In the event that I cannot be reached in an emergency, I hereby give permission to any licensed physician, surgeon, clinic, or hospital to secure proper treatment, and to order injection or anesthesia, for my child as named above. I hearby state my child is free from all communicable diseases and has not been treated for any disease within the past six months, and has received all required immunizations.
_________________________________________ PARENT OR GUARDIAN SIGNATURE	_________________________________________ DATE
NOTE: Hold Harmless and Medical Release form MUST be signed to skate
Admission Requirements and Park Rules
All Skaters/Media must have a valid photo I.D. to enter the park. Hold Harmless cards must be signed in person Minors need to have their parents sign the Hold Harmless card in person or the signature must be notarized All participants must wear knee pads, elbow pads, and a helmet Skating is restricted to the Skate Park ONLY. Skating outside the park will result in suspension of Skate Park privileges. THERE ARE NO EXECEPTIONS TO THESE RULES!!!!
NAME (print) ________________________________ ADDRESS___________________________________ CITY____________________ZIP_________________ PHONE (hm)_____________(wk)_________________ BIRTHDATE____________AGE_________________		EMERGENCY # Name________________________ Relationship__________________ Phone_______________________