Please print and fill out legibly for correct information!

Today's Date:__________________________                                                                    

First Name:________________________________  Last Name:_______________________________

Address:_____________________________________________________________________  

Lot/Apt. #:______________________________

City:__________________________________________  State:__________   Zip Code:______________________________

E-Mail Address:_________________________________________________

Birth Date:_________/___________/____________

Home Phone:  (                )___________ - _______________

Work Phone:  (                 )___________- _______________

IN CASE OF EMERGENCY, CALL:

EMERGENCY NAME:_________________________________________________

EMERGENCY PHONE NUMBER:________________________________________

Please list any health problems below:

                                     ___________________________________________________________________________________________________

                                     ___________________________________________________________________________________________________

In consideration of being allowed to participate in any way in the ZERO GRAVITY/Waterford Christian Association/Mt. Zion

athletic/sports program, related events and activities, I, _____________________________, the undersigned

                                                                                      (Name of Participant)

acknowledge, appreciate, and agree that:

1. The risk of injury from the activities involved in this program is significant, including the potential for

permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce

this risk, the risk of serious injury does exist; and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown. EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my participation; and,

3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence of participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Zero Gravity Skate Park, the Waterford Christian Association/Mt. Zion their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event ("Releasees"). WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

X________________________________________ Age:_____________ Date Signed___________________

(Participant's Signature)

FOR PARTICIPANTS OF MINORITY AGE

(UNDER 18 AT THE TIME OF REGISTRATION)

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin. I release and agree to indemnify the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES to the fullest extent permitted by law.

X_______________________________________     ______________________________________

(Parent/Guardian's Signature)                                            (Emergency Phone #(s))     

Date Signed:________________________