43 WAIVER, RELEASE, HOLD HARMLESS AND AGREEMENT NOT TO SUE I, the undersigned, fully understand that my and/or my child(ren)'s participation in the activity(ies), hereinafter referred to as “EVENT/CLASS” exposes me and/or my child(ren) to the risk of personal injury, death, communicable diseases, illnesses, viruses, or property damage. I hereby acknowledge my and/or my child(ren)'s voluntary participation in EVENT/CLASS and agree to assume any such risks. I hereby release, discharge and agree not to sue the City of Lakewood, hereinafter referred to as “CITY”, its officers, employees and agents for any injury, death or damage to or loss of personal property arising out of, or in connection with, my and/or my child(ren)'s voluntary participation in EVENT/CLASS from whatever cause, including the active or passive negligence of CITY, its officers, employees and agents or any other participants in EVENT/CLASS. The parties to this agreement understand that this document is not intended to release any party from any act or omission of gross negligence, as the term is used in applicable case law and/or statutory provision. In consideration for being permitted to participate in EVENT/CLASS, I hereby agree, for myself, my heirs, administrators, executors and assigns, that I shall indemnify and hold harmless CITY, its officers, employees and agents from any and all claims, demands, actions or suits arising out of or in connection with my and/or my child(ren)'s voluntary participation in EVENT/CLASS. I understand and agree that EVENT/CLASS may be recorded for viewing and/or listening by others during EVENT/CLASS and at a future date. I consent to CITY’s use of audio and video recordings and photographs of me and/or my child(ren) during EVENT/CLASS and that CITY may use audio and video segments or photographs of me and/or my child(ren) for any purpose, including but not limited to news, advertising and promotional purposes, without compensation to me and/or my child(ren). I hereby release and hold harmless CITY from any claims relating to the use of my and/or my child(ren)’s likeness and image. I HAVE CAREFULLY READ THIS RELEASE, HOLD HARMLESS AND AGREEMENT NOT TO SUE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT IT IS A FULL RELEASE OF ALL LIABILITY AND SIGN IT ON MY OWN FREE WILL. Date Signature Required Step 3 Participant Information Please list separately each participant and the activity information requested. 1. 2. 3. 4. Activity # Last Name First Name Activity Name Sex M/F Birth Date mm/dd/yy Fee Return to: City of Lakewood, P.O. Box 158, Lakewood, CA 90714 • 562 866-9771, ext. 2408 • lakewoodcity.org/recreation Print Name Method of Payment qCheck qMoney Order qCash Start Date LIFE Form (Lakewood Individual & Family Enrollment) Form If you’ve filled out the Lakewood LIFE Form in the past, please complete Steps 1 and 3. Please complete all steps if you have never filled out a LIFE form. q Check this box if you have a change of address, phone number or name. Be sure to also complete Step 2 with your up-to-date information. Step 1 First, give us your email address. Email: Step 2 Next, decide who the Main Contact is for your family. This is normally the person who is re- sponsible for signing up family members and paying for activities. (Note: Any refund processed for this account will be payable to the Main Contact.) Main Contact Last Name First Name MI Cell Phone Street Address Apt. No. Home Phone City Zip Code Birth Date (mm/dd/yy) ( ) ( ) If you are a qualified individual with a disability and need an accommodation to participate in this activity or program, please contact the Recreation and Community Services Department at (562) 866-9771 ext. 2408 at least 48 hours in advance. Total non-resident fees Total of activity fees Transaction Fee Total Paid $2.16 Concerts in the Park donation Camp T-shirt total Size(s)