Fillable Printable Minor Liability Waiver and Hold Harmless Agreement

Minor Liability Waiver and Hold Harmless Agreement

Innovators’ Workshop

Minor Liability Waiver and Hold Harmless Agreement

Parent or Legal Guardian

Individuals using the Innovators' Workshop are required to read the following information carefully and fully

understand before participating in any activity or program. You agree that your child(ren)

___________________________________________________are voluntarily participating with the

knowledge of the risks in doing so.

I, ________________________________, am fully aware that participation in the

(Name of Parent/Guardian)

Innovators' Workshop may result in risk of personal injury or harm to my child.

I hereby agree to release and hold harmless the Town of Simsbury, the Simsbury Public Library, their

respective Boards of Directors, agencies, officers, employees, committees, and volunteers, from and

against all liability, loss, damages, claims, or actions (including legal costs and attorney fees) for any bodily

injury and/or property damage, to the extent permissible by law arising from or related to his/her

participation.

This indemnification and hold harmless agreement shall include indemnity against all costs (including

without limitation, reasonable attorney's fees and court costs), expenses and liabilities incurred or in

connection with any such claim or proceeding brought thereon and in defense thereof.

In signing this release, indemnification and hold harmless form, I acknowledge that I have read and

understand fully the foregoing agreement, and sign it voluntarily as my own free act and deed; no oral

representations, statements, or inducements, apart from the foregoing written agreement, have been made.

I hereby give permission to the Simsbury Public Library for emergency transportation and/or treatment in

the event of illness or injury. I hereby accept responsibility for the payment of any emergency transportation

and/or treatment. I further certify that I am fully competent and my child is in good physical condition, and

have no medical or physical conditions that would restrict his/her participation in any program or activity.

_________________________________________ ___________________

Signature of Parent/Legal Guardian Date

________________________________________________________________________

Address

_____________________________________________ _________________________

email Address Telephone

_________________________________________________

Child/Minor’s Name, Age

Please check one:

_____ Teen, age 12-17

_____ Child, under age 12, an adult must supervise a child under the age of 12

Revised April 2014