b'Program Name: ________________________________ Program Level: _____________ Start Date: ____/____/____Session: _____________________________ Day(s) of Week: _________________________Time: _______________RELEASE ASSUMPTION OF AGREEMENT, AGREEMENT TO INDEMNIFY AND HOLD HARMLESS SIGNATURE: Prom agram Naware tme:hatl__earni__n__g o__r__ pa__rti__cipa___tin_g i__n t__h_e a__b_ov__e a____ctiv ityP croangr bam Le an aevcel:tiv _ity__ inv___ol__vin__g ri_s__k of S tiarnjuryt Dat, ince: lu_di___ng s/___erio_/u__s __ I a injury. I fully understand that the City of Portland, its agents, officers and employees accept no responsibility and will not Ses lisionbe able fo: __r a__ny_ i__njury___, h___arm or d_______am_a__ge_ t__o p__arti_ Dacipyan(s) tso propef Weerk:ty oc __c_urr__i__ng_ du__r_ing__ _or ar____is__ing o___ut __ofT paime:rtic __ipati___on o__ut__ of__ s_a__id_ program. To the fullest extent permitted by law, I do hereby agree to assume all risk of injury, harm or damage to participants person or property (including but not limited to participants property caused by negligence of the City of RELEASE ASSUMPTION OF AGREEMENT, AGREEMENT TO INDEMNIFY AND HOLD HARMLESS SIGNATURE: Portland, its agents, officers or employees) arising during or in connection with said program, and I do hereby release and I am aware that learning or participating in the above activity can be an activity involving risk of injury, including serious agree to indemnify and hold harmless the City of Portland, its agents, officers and employees from any and all liability, injury. I fully understand that the City of Portland, its agents, officers and employees accept no responsibility and will not actions, damages and claims of any kind and nature whatsoever (including but not limited to participants property caused be liable for any injury, harm or damage to participants property occurring during or arising out of participation out of said by negligence of the City of Portland, its agents, officers or employees) for injury harm or damage to participants property program. To the fullest extent permitted by law, I do hereby agree to assume all risk of injury, harm or damage to that may arise or occur during or in connection with said programs. I also agree to abide by any and all rules, regulations, participants person or property (including but not limited to participants property caused by negligence of the City of and policies of the above activity.Portland, its agents, officers or employees) arising during or in connection with said program, and I do hereby release and X (Participants Signature): _____________ortland, its agents, officers and employees from any an __/l_l _liab_/_il_ity_, _agree to indemnify and hold harmless the City of P__________________________________Date:_d aactions, damages and claims of any kind and nature whatsoever (including but not limited to participants property caused X (Parent/Guardian Signature): ____________________________________________Date: by negligence of the City of Portland, its agents, officers or employees) for injury harm or damage to partic_i_pa_/nt__s_ pro/___pe_rty that may arise or occur during or in connection with said programs. I also agree to abide by any and all rules, regulations, MEDICAL RELEASE:and policies of the above activity.Please list any allergies, medical conditions, physical limitations and/or restrictions the participant(s) may have: X ___/ _________ (__Par__t_i__cipa___nt___s S___ign__at__ure):____ ____________________________________________________________________________________________________D__ate:___ ____ ___/______I give my permission for emergency medical treatment to be given to participant in case a consulting adult cannot be X (Parent/Guardian Signature): ____________________________________________Date:___/___/____reached by phone. X ___/___/____M E(PDarICtiAcL REipantLEs SASignE:at ure):_______________________________________________D ate: Please list any allergies, medical conditions, physical limitations and/or restrictions the participant(s) may have: X (Parent/Guardian Signature): ____________________________________________Date:___/___/_____________________________________________________________________________________________________ I give my permission for emergency medical treatment to be given to participant in case a consulting adult cannot be PHOTOGRAPH RELEASE: reached by phone.X (Participants Signature): ______________________________________________ities or sp_ec_/ial__ ev_/_en__ts_. The Department of Recreation may take pictures or videos of participants at our programs, activ_Date:_Please be aware that the picture may appear in future promotional materials, including our brochure.X (Parent/Guardian Signature): ____________________________________________Date:___/___/____X (Participants Signature): _______________________________________________Date:___/___/____ XH ___/__/____ P (POarenTOGtR/GAuaPHrd RianEL SEiAgSnaEt:ure) : ____________________________________________D ate:_ The Department of Recreation may take pictures or videos of participants at our programs, activities or special events. Please be aware that the picture may appear in future promotional materials, including our brochure.Parks, Recreation & Facilities NewsletterOnce a month, we send out valuabl_____________rding all the exciting things that take place within the __ep/__artm_/__en__t.X (Participants Signature): __e information rega________________________________Date:_ D Would you like to receive our monthly newsletter? (please circle one)Yes: No: X (Parent/Guardian SPLEAignaStEure) MAKE: _ _C_HE__C_K_S PA___YA__B_LE __TO_ C_ __I_T_Y _OF__ POR____TLA__N__D____________Date:___/___/____how did you hear about us?: web search current customerPayment: City of Portland Parks, Recreation & Facilities offers the convenience of accepting MasterCard, Discover, friend ter Parks, Recreation & Facilities Newslet facebook other ____________________ American Express and Visa credit cards. The payment processing company charges a $3 minimum service charge fee for Omncailinge a month, we send out valuable informatinonewslet regaterrding all the exciting things that take place within the Department. a charge up to $114 and 2.65% thereafter to cardholders who use this service. Would you like to receive our monthly newsletter? (please circle one)Yes: No: $ CreditPLEASE MAKE CHECKS PAYABLE TO CITY OF PORTLANDExp. Amount Due Card #Date Optional Scholarship Donation $ Payment: City of Portland Parks, Recreation & Facilities offers the convenience of accepting MasterCard, Discover,($5.00) American Express and Visa credit cards. The payment processing company charges a $3 minimum service charge fee for Total Amount Due$a charge up to $114 and 2.65% thereafter to cardholders who use this service.Thank you for using Portland Recreation & Aquatic Programs! $ CreditExp.Yes AmNoou nt Due Card #I HAVE A CITY OF PORTLAND FEE WAIVER:Date Optional Scholarship Donation $($5.00) Use Only Visa/MC Amount Check #eFor OfficeTotal Amount Due r Lev lFee Waive $ Thank you for using Portland Recreation & Aquatic Programs! DateCash Amount Check Amount A B FULLI HAVE A CITY OF PORTLAND FEE WAIVER:YesNoFor Office Fee Waiver LevelUse Only Date Visa/MC Amount Check # Cash Amount Check Amount A B FULL'