Pinecrest Parental Permission Slip
ACKNOWLEDGMENT
/ AGREEMENT / WAIVER / ASSUMPTION OF RISK TO INDEMNIFY MINOR & ADULT
SKATEBOARDING PARTICIPANTS. (NOTE) Pinecrest Christian Conference Center (PCCC)
requires a signed form from each participant.
MANDATORY
SAFETY ATTIRE: I agree to wear the Mandatory Safety Attire whenever I use the
skateboard ramp. This includes: Helmet, kneepads, elbow pads, and shoes.
Participant
(Please Print)______________________________________________________
Home
Address ___________________________________________________________________
City____________________________________________State___________________ZIP_____
Phone________________________Birthday_____________________Age__________
Parent/Guardian_________________________________ Home Phone___________________
Work
Phone_______________________ Pager Number__________________________.
In
order to be granted. Permission to become a participant in the skateboard
activities of PINECREST SKATEBOARD PARK, I understand I subject myself to the
following conditions, requirement and agreements:
1.
The undersigned
person(s)(minor participant and parent/Legal Guardian of the same, or the
above named adult Participant) understands, acknowledges, and agrees that this
document applies whether the participant is an observer, bystander, or
actually on the ramp: whether the activity is at the above stated premises, or
other PCCC properties or designated parks
2. The Participant agrees that at All times he/she wi11 obey all the
Skateboard Park Staff, Counselors, Volunteers, and all the, Skateboard Park
rules during activities.
3.
The Participant
understands, acknowledges, and agrees that skateboarding and in-line skating
are dangerous and can result in injury (even death), or damages to his/her
Property, and is fully aware of the risks and hazards inherent to such
activities and hereby elects voluntarily to participate, knowing the present
condition of all ramps and equipment.
4.
The Participant hereby. Voluntarily assumes all risk of loss, damage ,
injury or death that may be sustained by him/her and any damage to his/her
Property while in the Skateboard Park. The Participant understands that
various degrees of experience and skill are required for the different skating
surfaces and agrees that it will be his/her sole judgment as to whether he/her
will attempt to skate.
5.
The Participant agrees to complete Skateboard Park training and the inspection of any personal
equipment prior to receiving clearance by Staff to participate in these
activities.
6.
I understand and agree that it is inherently impossible for any supervisor to control the activity of every user and that different
users will be traveling on different equipment, at different speeds, in
different directions, which could result in collisions. I agree I will not use
any equipment, which is beyond my skill level. I agree that the above listing
of certain specific risks is not intended to be exclusive and that there are
many other ways in which I, or my property may be injured, destroyed or
otherwise affected If, at any time, Staff determines an activity, ability, or
equipment is inappropriate, the Participant will immediately cease
participation until clearance to do so is re-authorized by Staff.
7.
The undersigned hereby releases PCCC on behalf of the above named
Participant, his/her heirs,
assigns
and/or legal representatives from any and all liability for personal injuries
or
9.
PCCC may immediately revolt this agreement for violations of any of its
terms.
In Case of
Emergency
Notify____________________________________
Relationship__________________________
Phone/Pager________________________________-
The undersigned does
hereby authorize, PINECREST CHRISTIAN CONFERENCE CENTER (PCCC) and Pinecrest
Skateboard Park to consent to IMMEDIATE FIRST AID MEDICAL CARE, and X-ray,
examination, anesthetic, medical, dental or surgical diagnosis or treatment
and hospital care for the participant which may be deemed advisable by and to
be rendered under the genera I
or special supervision of any appropriate licensed physician, surgeon, and/or
dentist, whether such diagnosis is rendered in office, hospital, or elsewhere.
It is
understood that an effort shall be made to contact the undersigned prior to
rendering treatment to the patient, but that any of the above treatment will
not be withheld if the undersigned cannot be reached, it is also understood
that the person preventing this authorization is acting as my/our agent and
will not be liable for treatment rendered.
I further understand that my insurance will cover
any treatment and PCCC will not be liable.
This authorization
will remain effective while the minor is in route to or from or involved,
participating" observing, or standing by any program or activity of
Skateboard Park.
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Parent/Legal
Guardian's Signature_________________________________________
Date_________________
As
the Parent/Legal Guardian of the above listed minor participant, I have read,
understand and consent to the terms state and implied within this document and
to the minor becoming a participant.
Adult participant
Signature___________________________________________ Date________________
As the participant listed above, I read and understand and consent to the terms state and implied within this document. I attest that I am physically fit and have sufficiently trained for this activity.
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