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Head of Household First Name*
Head of Household Last Name*
Address*
City*
State*
Zip*
Date of Birth*
Date of Birth
Gender *
Email Address*
Home Number*
Please use Format (111)123-1234
Work Number*
Please use Format (111)123-1234
Cell Number*
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Spouse Info - If none, please use N/A for all required fields (01/01/1900) for DOB

Spouse First Name*
Spouse Last Name*
Address - If different from Head of Household
City
State
Zip
Date of Birth *
Date of Birth
Gender*
Email Address - If different from Head of Household
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Additional Household Members - If none, please use N/A for all required fields (01/01/1900) for DOB

First Name*
Last Name*
Date of Birth*
Date of Birth
First Name*
Last Name*
Date of Birth*
Date of Birth
First Name*
First Name*
Date of Birth*
Date of Birth
First Name*
Last Name*
Date of Birth*
Date of Birth
Special Assistance*
Do any of these participants require special assistance? If YES, please contact Sean Ward at 440-442-2626 x400
1. Yes
2. No
If answered yes to above question, please specify who
Agreement to indemnify, and not sue, the city and release of all claims
As a participant in this and any other program of the Mayfield Heights Parks and Recreation Department, I, for myself or the participant for whom I sign (if under 18 years of age), recognize and acknowledge that I/we may be exposed to a variety of risks and I/we agree to assume all such risks, including but not limited to, any damage resulting from physical injuries, death, loss of services or consortium, loss or damage to property, or any other loss or injury I/we may sustain as a result of participating in any and all activities connected or associated with such programs. I acknowledge that I/we have no physical limitations, or disabilities of any kind which would restrict me/us from participating. Any special accommodations needed have been noted or will brought to the attention of the Mayfield Heights Parks and Recreation Department
In consideration of the Mayfield Heights Parks and Recreation Department accepting my/ our registration and with the intent to be legally bound, I hereby, for myself or the participant for whom I sign (if under 18 years of age) and all heirs, executors, administrators and assigns: (1) forever release, waive and relinquish any claim I/ we have or may have as a result of participating in this and all other programs of the City of Mayfield Heights Parks and Recreation Department; and (2) promise not to sue and agree to hold harmless and defend, the City of Mayfield Heights and its officers, officials, agents, employees, volunteers, independent contractors, and other representatives (referred to collectively hereinafter as "City of Mayfield Heights") from any and all claims, liabilities, demands, actions or causes of action in any way resulting from my/our participation in this and all other programs of the Mayfield Heights Parks and Recreation Department.
USE OF PHOTOGRAPHS: I do hereby grant and give the City of Mayfield Heights the right to use my photograph or image (or the photograph or image of the participant for whom I am signing) with or without my/our names, both single and in conjunction with other persons or objects for any and all purposes including, but not limited to, private or public presentations, advertising, publicity and promotion relating hereto. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold the City of Mayfield Heights harmless of and from any and all liability of whatever nature, which may arise out of result of such uses.
PLEASE READ CAREFULLY, BY SIGNING YOU WAIVE CERTAIN LEGAL RIGHTS.
Date
Date
Signature of Participant*
Parent/Guardian (if participant is under 18 years old)

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Spouse Info - If none, please use N/A for all required fields (01/01/1900) for DOB

Additional Household Members - If none, please use N/A for all required fields (01/01/1900) for DOB

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