Pure Hart Basketball- Waiver & Information
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What is your Child's First and Last Name? *
What is your first and last name? *
What is the best emergency contact name & number for your child while in the program. *
Please list a second emergency name & contact number for your child while in the program. *
Does your child have any allergies or medical conditions we should be aware of? If so, please describe. Please write none if there are no conditions staff should be aware of. *
IN CONSIDERATION of gaining membership or being permitted to utilize the facilities, services, and programs of the YMCA (or for my children to so participate) for any purpose including but not limited to observation or use of facilities, equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, or next of kin hereby acknowledges, agrees, and represents that he or she has or immediately upon entering or participating will inspect and carefully consider such premises and facilities of the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities, equipment, or participation in such affiliated programs constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated programs have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use, or participation.IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSEINCLUDING BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES, EQUIPMENT, ORPARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNEDHEREBY AGREES TO THE FOLLOWING: #1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES,AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, and agents(hereinafter referred to as releases) from all liability to the undersigned, his personal representatives, assignees, heirs, and next of kin for any loss or damage or any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releases or otherwise while the undersigned is in, upon, or about the premises, facilities, or equipment therein or participating in any program affiliated with the YMCA. #2. THE UNDERSIGNED HEREBY AGREES TOINDEMNIFY, SAVE, AND HOLD HARMLESS the releases from any loss, liability, damage, or cost they may incur due to the presence of the undersigned in, upon, or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releases or otherwise. #3. THEUNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY,DEATH, OR PROPERTY DAMAGE due to negligence of releases while in, about, or upon the premises of the YMCA and/or while using the premises, facilities, or equipment thereon or participating in any program affiliated with the YMCA. #4.The YMCA does not condone staff privately providing childcare for program participants. Parents or guardians who hire child care providers from among YMCA staff understand that the YMCA is not responsible for staff who conduct outside employment and hereby releases the YMCA from any liability for acts or omissions of any staff who provide child care outside of YMCA employment. #5.By signing this Agreement I hereby give my permission for the YMCA to take my photograph or a photograph of my children and use or publish this likeness for YMCA purposes and I release the YMCA from any claims for such use. #6. By participating in the YMCA Nationwide Membership Program, I agree to release the National Council of Young Men's Christian Associations of the United States of America, and its independent and autonomous member associations in the United States and Puerto Rico, from claims of negligence for bodily injury or death in connection with the use of YMCA facilities, and from any liability for other claims, including loss of property, to the fullest extent of the law. THEUNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER OFLIABILITY/INDEMNITY AGREEMENT/PHOTO RELEASE is intended to be as broad and inclusive as is permitted by the law of the State of Massachusetts. If any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HASREAD AND VOLUNTARILY SIGNED THE RELEASE AND WAIVER OF LIABILITY/ INDEMNITYAGREEMENT/PHOTO RELEASE and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. As a community conscious member I will behave in a responsible way that respects the rights, safety and dignity of all YMCA members.  As such I agree to; not visitor participate at the YMCA if I have a fever or symptoms of illness.  Create a safe and caring environment by abiding by social and physical distancing requirements.  Use a face covering or cover my face and nose as appropriate.  Follow hand sanitizing and hand washing protocol while in the YMCA. Clean all equipment before and after use.  Use one piece of equipment and move to the next after cleaning.  Acknowledge members need for personal space.  Limit my visit to 90 minutes to allow fellow members to enjoy our facility.  Speak in a respectful tone while discussing social distancing or other concerns. *
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