301 Second Street, Buellton
tel: (805) 688-1086
Rec Center Office Hours:12:00 noon - 6:00 p.m. Monday - Friday
Registration

Youth Registration (17 and under)

Release and Waiver of Liability and Assumption of Risk Agreement

Please complete the following form. All fields are required unless specified.

Activity

Participant's Information

Parent/Guardian Information

Contact Information

Emergency Contact Information

Additional Information


If yes, please list below.

Additional information that the City of Buellton should be aware of?

Terms & Conditions

In consideration for permission for the above stated minor (“Minor”) to participate in the above selected event, activity or class (“Event”), the undersigned parent/guardian accepts, for myself, the Minor, our heirs, administrators, executors, and assigns, (“collectively “Undersigned”) agrees as follows. 

The Undersigned fully understands that participation in the Event involves the risk of illness, personal injury, death, or property damage. I hereby acknowledge that I am voluntarily participating in this Event and agree to assume any such risks.

In the event of injury or illness to the Minor during the Event, the City of Buellton, the City of Solvang, and their respective designees (“Cities”) are authorized, on behalf of the Undersigned, to employ or utilize any emergency medical facility and the registered physicians or surgeons licensed under the provisions of the medical staff of the facility to perform any diagnosis or treatment Cities deem necessary in their reasonable discretion. The Undersigned understands that the Undersigned is responsible for any and all medical bills and related charges incurred by Cities in obtaining treatment or diagnoses on behalf of the Undersigned.

The Undersigned hereby releases, discharges, and agrees not to sue the Cities of Buellton or Solvang, their officers, employees, agents, and volunteers (“City Parties”), for any and all losses, damages, including, without limitation, consequential and incidental damages, injuries, expenses, including, without limitation, court costs, attorneys’ fees, expert fees, fines, and penalties, claims, or liabilities of any kind, nature or description, including, without limitation, personal injury, death, or damage to or loss of personal property arising out of, in connection with, or in any way attributable, in whole or in part, to participation of the Minor in the Event from whatever cause, including, but not limited to, the active or passive negligence of City Parties, third parties, or any other participants in the Event, the Minor’s travel to or from the Event, and any exercises of authority by Cities in obtaining any medical diagnoses or treatment on behalf of the Minor (“Claims”).  This agreement shall not release any party from any act or omission of “gross negligence,” as that term is used in applicable case law and/or statutory provision.

The Undersigned hereby agrees to defend with counsel reasonably acceptable to the defendant, indemnify, and hold harmless City Parties from any and all such Claims by third parties.  The foregoing indemnification shall include any Claims or other liabilities of any kind, nature or description arising out of, in connection with, or in any way attributable, in whole or in part, to false warranties of the ability of the Undersigned to sign the agreement on behalf of the Minor.

THE UNDERSIGNED HAS CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTANDS ITS CONTENTS. THE UNDERSIGNED IS AWARE THAT IT IS A FULL RELEASE OF ALL LIABILITY AND SIGNS IT ON HIS/HER OWN FREE WILL.

The Undersigned hereby grants Cities, without expectation of compensation of any kind, the unrestricted right and permission to copyright and use, re-use, publish, and republish photographic portraits or pictures of the Minor or in which the Minor may be included intact or in part, composite or distorted in character or form, without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for illustration, art, promotion, advertising, trade, or any other purpose whatsoever.

The undersigned parent/guardian of the Minor grants permission for the Minor to participate in the Event, and accepts full responsibility for delivering the Minor to the Event at the appointed time and picking up the Minor at the conclusion of the Event. 

I hereby warrant and certify that I am the parent or guardian of the Minor, and do hereby give my consent, without reservation, to the foregoing on behalf of the Minor.

The above terms constitute a contract.  By checking this box you agree to enter into an electronic contract with the City of Buellton and the City of Solvang, the terms and conditions of which are stated above.