HomeMy WebLinkAboutParksWaiverAgreement for Assumption of Risk, Indemnification, Release, and
Consent for Emergency Treatment
Event Name: Date(s)
My son/daughter/ward, (print name), age , desires to participate
voluntarily in volunteer services for the City of Oshkosh.
I UNDERSTAND THAT I AM BEING ASKED TO READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. I
UNDERSTAND THAT IF I WISH TO DISCUSS ANY OF THE TERMS CONTAINED IN THIS AGREEMENT, I MAY CONTACT
THE OFFICE OF THE CITY ATTORNEY, AT THE TELEPHONE NUMBER (920) 236-5115.
Assumption of Risks:
I understand that physical activity related to volunteer services, by its very nature, carries with it certain inherent risks that cannot be
eliminated regardless of the care taken to avoid injuries. Some of these involve strenuous exertions of strength using various muscle
groups, some involve quick movement involving speed and change of direction, and others involve sustained physical activity, which
places stress on the cardiovascular system. The specific risks vary from one activity to another, but in each activity the risks range from:
1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as fractures, internal injuries, joint or back injuries,
heart attacks, and concussions to 3) catastrophic injuries including paralysis and death. I understand that the City of Oshkosh has advised
me to seek the advice of a physician before my son/daughter/ward participates in this activity. I understand that I have been advised to
have health and accident insurance in effect and that no such coverage is provided for me by the City of Oshkosh. I KNOW,
UNDERSTAND, AND APPRECIATE THE RISKS THAT ARE INHERENT IN THE ABOVE-LISTED PROGRAMS AND
ACTIVITIES. I HEREBY ASSERT THAT MY SON/DAUGHTER/WARDS PARTICIPATION IS VOLUNTARY AND
THAT I KNOWINGLY ASSUME ALL SUCH RISKS.
Signature of Parent or
Guardian: Date: / /
Hold Harmless, Indemnity and Release:
In consideration of permission for my son/daughter/ward to voluntarily participate in volunteer services, today and on all future dates,
I, for myself, my heirs, personal representatives or assigns, agree to defend, hold harmless, indemnify and release the City of Oshkosh,
and it’s officers, council members, agents, employees and authorized volunteers, from and against any and all claims, demands, actions,
or causes of action of any sort on account of damage to personal property, or personal injury, or death which may result from my
son/daughter/wards participation in the above-listed program. This release includes claims based on the negligence of the City of
Oshkosh, and it’s officers, council members, agents, employees and authorized volunteers, but expressly does not include claims based
on their intentional misconduct or gross negligence. I UNDERSTAND THAT BY AGREEING TO THIS CLAUSE I AM
RELEASING CLAIMS AND GIVING UP SUBSTANTIAL RIGHTS, INCLUDING MY RIGHT TO SUE.
Signature of Parent or
Guardian: Date: / /
Consent for Emergency Treatment:
I authorize the City of Oshkosh and its designated representative to consent, on my behalf, to any emergency medical/hospital care or
treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY
CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS
AUTHORIZATION.
Signature of Parent or
Guardian: Date: / /