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Congerville Eureka Goodfield Community Youth Recreation Association

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Download a Copy by clicking the link - communical disease release form.pdf

RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT

COMMUNICABLE DISEASE

7/28/2020

Participant’s Name___________________________________________Birthdate___________________

Street Address___________________________________________City___________Zip_____________

Parent/Guardian’s Name_________________________________Emergency Phone_________________

Parent/Guardian’s Name_________________________________Emergency Phone_________________


In consideration of being allowed to participate in any way in any CEGCYRA programs, related events, and/or activities, I the undersigned, acknowledge, appreciate, and agree that:

I am aware that there are risks to me of exposure, whether directly or indirectly, arising out of, contributed to/by, or resulting from an outbreak of any and all communicable diseases, including but not limited to, the virus “severe acute respiratory syndrome coronavirus (SARS-CoV-2)”, which is responsible for Coronavirus Disease (COVID-19) and/or any mutation or variation thereof. 

I, on behalf of myself, and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE CONGERVILLE, EUREKA, GOODFIELD COMMUNITY YOUTH RECREATION ASSOCIATION, its MEMBER LEAGUES AND CLUB, its directors, officers, officials, agents and/or employees, associated personnel, other participants, sponsors, advertisers, and if applicable owners and lessors of premises used to conduct the event (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any ILLNESS, INJURY, DISABILITY OR DEATH I may suffer, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. 

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

X_________________________________________________________ ____________ ______________                
Signature of Participant aged 18 or older Age Date

FOR PARENTS/GUARDIANS OF PARTICIPANT UNDER AGE 18 (MINOR) AT TIME OF REGISTRATION

This is to verify that I, as parent/guardian of __________________________ with legal responsibility for this Participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incidents to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENE OF THE RELEASEES, to the fullest extent permitted by law.


X___________________________________________________________________ ________________________                                                                         Signature of Parent/Guardian for Participant under age 18 Date

X__________________________________________________ __________________                             
Signature of Parent/Guardian for Participant under age 18 Date


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Eureka, Illinois 61530

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