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5. Release, Waiver and Indemnification Agreement (“Agreement”) for Minors
7. Program or Activity*
9. Participant Name*
11. Birth date*
    Birth date
12. Today's Date
    Today's Date
14. Address*
16. City*
17. State*
18. Zip Code*
20. Email Address
22. Natural Guardian Name*
23. Relationship*
24. Cell Number
26. Natural Guardian Name*
27. Relationship*
28. Cell Number*
30. Emergency Contact*
31. Cell Phone
33. Physician's Name*
34. Cell Phone
36. Medical Conditions*
40. Notice to the Minor Child's Natural Guardian
42. Pursuant to § 774.301, Fla. Stat. (2010)
    READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF THE CITY OF NORTH MIAMI USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM THE CITY OF NORTH MIAMI A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND THE CITY OF NORTH MIAMI HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
44. The undersigned natural guardian(s) whose name(s) appear above, voluntarily consent and agree that the above named minor child may participate in this non-commercial, community oriented or school supported program / activity.
46. By executing this document, the undersigned further agree to the following:*

    1. WAIVE ANY CLAIM against the City of North Miami (“City”) and its officers, agents and employees arising from any loss, injury, or damage to person or property and does COVENANT NOT TO SUE the City and
    2. RELEASE, INDEMNIFY, AND HOLD HARMLESS the, City and its officers, agents and employees from any and all claims, suits, actions, demands, rights, court judgments or expenses arising from or by reason o
    3. Nothing contained in this Agreement is any way intended to be a waiver of the limitation placed upon the City’s liability as set forth in Section 768.28, Florida Statutes. Additionally, the City does
    4. Authorize the City of North Miami and its officers, agents, employees and/or sponsors to call my physician and/or to arrange for transportation to a hospital in the event of any injury to the particip
    5. Authorize the City to depict for any purpose, without paying compensation to me or our child, my name, image, or the likeness of me or my child in photographic or other works appearing in any and all
    6. In the event participant is under the age of 18, both parents or guardians of participant, consent and agree that the program / activity named above, provides the participant child with an essential e
    7. In the event any portion of this Agreement is deemed to be void, the undersigned specifically agree to waive any and all claims, including but not limited to claims for medical expenses, future cost o
    8. The City desires to enter into this Agreement only if in so doing the City can place a limit on its liability for any cause of action for money damages or arising out of this Agreement, so that its li
    9. This Agreement shall be binding on all heirs, successors and assigns of participant, or if participant is under the age of 18, of each parent or guardian.
48. All of the undersigned have fully read, understood and agree to each and every term contained in this Release, Waiver and Indemnification agreement.
50. Witness Signature
51. Print Witness Name
53. Natural Guardian Signature
    (if participant is under the age of 18)
54. Print Natural Guardian Name
56. Address
58. City
59. State
60. Zip Code
62. Phone Number
Leave This Blank:


63. Print Only

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