Activity Waiver

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Acct #

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Member #

Activity 2026(Required)

Please select the activity that this waiver applies to.

Aqua Aerobics

Campout

Master Swim

Yoga

Start Date of Activity(Required)

mm/dd/yyyy

Member Name(Required)

Person who is filling out the waiver

First Last

Member phone number(Required)

Member Email(Required)

Who is the waiver for?(Required)

Myself

Myself and my children

Another responsible Adult with my child

For any overnight activities such as campouts all children under the age of 18 need to have a parent or responsible party with them to stay overnight.

If another adult member of MVPA will be responsible for your children during this activity you must enter their information below:

Responsible Adult(Required)

Responsible first Responsible last

Phone number of responsible adult(Required)

List of Attendees(Required)

This waiver applies to all family members attending the event. Please list the FIRST and LAST name of all attendees in this field.

Emergency Contact(Required)

Em first name Em last name

Emergency Contact Phone Number(Required)

Consent(Required)

MVPA ACCIDENT WAIVER AND RELEASE OF LIABILITY

By signing this Waiver, I assume all risk of my child and/or myself participating in the above activity (hereinafter “activity”). Without signing this form, neither myself nor my child will be able to participate in the activity. I acknowledge that the above activity may pose some risk of personal injury and that I undertake and assume this risk for myself and my child.

On behalf of myself and my child, I further waive and release the Mount Vernon Park Association, Inc., its insurer, directors, officers, employees, volunteers, agents, representatives, or assigns, (collectively, the “MVPA Entities”) from any and all liability, including, but not limited to, liability arising from negligence or fault of the MVPA Entities for any injury or disability which may occur as a result of my or my child’s participation in the above activity. I am assuming all risks on behalf of myself and my child that may arise from negligence or carelessness on the MVPA Entities related to the activity, as well as from defective equipment, real property or personal property that is owned, maintained or controlled by the MVPA Entities.

I CERTIFY THAT MY CHILD AND MYSELF ARE PHYSICALLY FIT AND SUFFICIENTLY PREPARED FOR PARTICIPATION IN THE ACTIVITY AND THAT THERE ARE NO HEALTH RELATED REASONS OR PROBLEMS WHICH WOULD PRECLUDE THE PARTICIPATION OF MYSELF OR MY CHILD IN THE ACTIVITY. I HAVE NOT BEEN ADVISED OF ANY REASON WHICH WOULD LIMIT MY CHILD OR MYSELF IN PARTICIPATING IN THE ACTIVITY.

I consent to receive any medical treatment deemed advisable for an injury to myself or my child during the activity and that any medical or other insurance for myself and/or my child will be insurance of first resort before contribution by any other insurance for any other person or entity, including accidental death and dismemberment insurance and accident medical insurance.

I shall defend, hold harmless, and indemnify the MVPA Entities from and against all losses, claims, damages, costs or expenses (including reasonable legal fees, or similar costs) in connection with any action or claim brought or made (or threatened to be brought or made), for, or on account of any injuries or damages, received or sustained by myself and/or my child arising during the course of the activity.

This Agreement constitutes the sole and only agreement between the parties concerning my child’s and my release and indemnification as a condition for participating in this activity.
Any prior agreements, whether oral or in writing, shall be void and of no further effect. This Agreement may not be modified.

I certify that I have read this document, and I fully understand its contents. I am aware that this is a release and indemnification of liability for myself and my children, and I sign it of my own free will.

Signature

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