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Today's Date: September 20, 2021

CONSENT AND RELEASE AND HOLD HARMLESS AGREEMENT

I, or the parent/legal guardian of named minor child(ren) user(s)/participant(s) do hereby consent to, understand, acknowledge and agree to assume all risks and hazards incidental to my or my minor child’s use of the City of Fernandina Beach Parks & Recreation facilities, parks and beaches and participation in programs offered by the City of Fernandina Beach Department of Parks and Recreation.  Furthermore, I do expressly understand and agree that if I or my minor child has a medical condition, I am under no obligation to disclose this condition to City personnel, and I hereby expressly assume all risks and hazards incidental to my or my minor child’s use of the City of Fernandina Beach Parks & Recreation facilities, parks and beaches and participation in programs offered by the City of Fernandina Beach Department of Parks and Recreation.

I do further promise and hereby further agree to waive, release, absolve, and covenant not to sue the City of Fernandina Beach, its employees, contractors, subcontractors, suppliers, materialmen, officers, volunteers, representatives, attorneys and agents, for any and all claims, including claims for equitable or injunctive relief, damages, loss or injury of any kind resulting from or in any way arising directly or indirectly out of my or my minor child’s use of the City of Fernandina Beach Parks & Recreation facilities, parks and beaches and participation in programs offered by the City of Fernandina Beach Department of Parks and Recreation.  THIS RELEASE INCLUDES A RELEASE FOR ANY AND ALL LOSSES OR INJURIES ARISING OUT OF ANY AND ALL NEGLIGENT OR WRONGFUL ACTS OR OMISSIONS OF CITY OF FERNANDINA BEACH, ITS EMPLOYEES, CONTRACTORS, SUBCONTRACTORS, SUPPLIERS, MATERIALMEN, OFFICERS, VOLUNTEERS, REPRESENTATIVES, ATTORNEYS AND AGENTS.

I further promise and agree to indemnify, defend and hold harmless, its employees, contractors, subcontractors, suppliers, materialmen, representatives, officers, volunteers, attorneys and agents from and against all liability, claims and expense, including reasonable attorneys’ fees and costs, in connection with any and all claims whatsoever for personal or bodily injury or death, including loss of use, or property damage of any kind and character in connection with and arising directly or indirectly out of my or my minor child’s use of the City of Fernandina Beach Parks & Recreation facilities, parks and beaches and participation in programs offered by the City of Fernandina Beach Department of Parks and Recreation.  This indemnity agreement encompasses all damages and claims, including claims for equitable or injunctive relief, arising out of my or my child’s use of the City of Fernandina Beach Parks & Recreation facilities, parks and beaches and participation in programs offered by the City of Fernandina Beach Department of Parks and Recreation.

THIS RELEASE IS GIVEN AND SIGNED OF MY OWN FREE ACT AND WILL.  THE UNDERSIGNED IS COMPETENT, AT LEAST EIGHTEEN (18) YEARS OF AGE OR OLDER AND HAS AUTHORITY TO EXECUTE THIS DOCUMENT.

Today's Date: {date}

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
Parent or Guardian's Email Address

Email*
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Program/Trip Information

Invasives removal *

Today's date *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

VOLUNTARY INFORMATION:


Please list and describe any medical conditions or special needs that you may wish to share with our staff in order to maximize your safety and enjoyment while at our facility(s) and/or while participating in our programs.
PHOTO RELEASE AUTHORIZATION: I give permission to the City of Fernandina Beach to take and publish photographs, digital images and/or videotaped images of me for news, advertising and/or promotional purposes in print and electronic media. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. Neither the City of Fernandina Beach, nor its officers, employees, elected and appointed officials, or agents shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby forever release and discharge the City of Fernandina Beach, its officers, employees, elected and appointed officials, and agents from all such claims, demands, actions, or causes of action. PLEASE CHOOSE ONLY ONE RESPONSE BELOW. *
I have read, understand and agree to the photo release authorization terms above.
I do not agree to the photo release terms above and have shared my wishes with my child(children). I understand that it is my child's responsibility to notify staff of this decision when photos/imagery is/are in progress.
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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