Family Release

07/14/2022

Family Waiver and Release of Liability

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Name*
Address*
I, the undersigned, recognize and acknowledge that there are certain risks of physical injury to participants who attend
the above event and I agree to assume the full risk of any injuries, damages or loss regardless of severity which I may
sustain as a result of participating in any and all activities connected with or associated with such an event.
 I, the undersigned, do hereby grant permission to Boys & Girls Club of Bloomington-Normal (BGCBN) to use my image.
Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or
video taken of myself for use in materials that include, but may not be limited to, printed materials such as brochures
and newsletters, videos, and digital images.
 I, the undersigned, authorize Boys & Girls Club of Bloomington-Normal to run a local, state and federal background
check.
 I agree to waive and relinquish all claims I may have against the Boys & Girls Club of Bloomington-Normal and its
employees as a result of participation in the event. I do hereby give full release and discharge BGCBN and its employees
from any and all claims from injuries, damages, or losses which I may have or which may accrue to me arising out of it,
connected with, or in any way associated with the activities of BGCBN.
 I further agree to indemnify and hold harmless and defend BGCBN and its employees from any and all claims resulting
from injuries, damages and losses sustained by me arising out of, connected with, or in any way associated with the
BGCBN event.
 In the event of an emergency, I authorize BGCBN to secure from any licensed hospital, physician and/or medical
personnel any treatment deemed necessary for my immediate care and agree that I will be responsible for payment of
any and all medical services rendered.
 I further understand that I must follow all safety rules and instructions given by the employees of BGCBN and failure to
do so may result in suspension from BGCBN. I have read fully and understand the above waiver and release all claims,
agree to follow the rules and give permission to secure treatment.
By typing in your name, this creates a legally binding signature.
Today's Date

If you would like to download this form, sign and mail it, click here: Family Release 2022 - 2023