Waiver and Release From Liability/ Assumption of Risk, Medical Treatment Consent and Consent to Photograph Form

I, the undersigned, wish to participate in, or if signing on behalf of my minor child/children, wish my child to participate in, one or more activities (hereinafter collectively referred to as 'the Activity') conducted in collaboration with the City of Benicia's Parks and Community Services Department. I am aware that serious accidents and injuries occasionally occur during recreational pursuits such as the Activity. In consideration of participation in the Activity, I knowingly and voluntarily assume all risks arising therefrom, and on behalf of myself, my heirs and assignees, release the City of Benicia, its elected officials, officers, agents, employees and volunteers from any and all claims, liens, damages, lawsuits, or liability for property damage, injury or death, resulting from, and arising out of, or in any way connected with my or my minor child/children's participation in the Activity.

I agree and acknowledge that this Waiver and Release From Liability/Assumption of Risk shall apply even in the event that I or my minor child suffer death, personal injury, or property damage as a result of passive or active negligence on the part of the City of Benicia, its elected officials, officers, agents, employees, or volunteers of the City (with the exception of sole, active negligence or willful misconduct). In the event that the individual participating in the Activity is a minor, I certify that I am his/her parent or legal guardian, and I give my permission for him/her to participate in the Activity. I understand my signature is a legal and binding signature and will be considered original if received by fax or electronic means.

Medical Treatment Consent

In the event I or said minor requires medical treatment while under the supervision of City staff or agents, I authorize the City of Benicia or its authorized representatives to provide and/or authorize medical treatment. I expect City staff to contact me immediately in the event of emergency medical treatment for said minor, but this contact is not necessary to administer emergency aid. I will pay for all medical treatment which I or said minor may require.

Use of Participant Photographs/Video

In addition to the foregoing, I give consent to the City of Benicia Parks and Community Services Department or any other media agency authorized by the City of Benicia, to photograph or video me (or minor on whose behalf I am signing this waiver), and use such photographs/video footage in brochures, newspapers or other forms of media describing City of Benicia activities. I agree to advise the City of Benicia Parks and Community Services Department in writing if I do not agree to the foregoing.

Waiver of Liability: I, the undersigned, in consideration of my participation or my minor child/children's participation in the program(s) listed above, state that I have read the 'Waiver and Release From Liability/ Assumption of Risk, Medical Treatment Consent and Consent to Photograph' document on the previous page and agree to the terms and conditions listed in the document.

Signature:_____________________________________________________________________Date:______________

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