CHILD'S INFORMATION
LEGAL GUARDIAN'S INFORMATION
We will get more of your information in the formal registration in the next step
EMERGENCY CONTACT INFORMATION
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MEDICAL INSURANCE INFORMATION
FAMILY PHYSICIAN
PARENTAL RELEASE
Please read each agreement carefully
I agree to allow my child/ward to be in photos/videos and understand that the image/video may be used or published without acknowledgement or compensation.
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT
In consideration for being permitted to utilize the facilities, services, and programs of the Rogers Activity Center (RAC) and Rogers Community School Recreation Association (RCSRA) for any purpose, including but not limited to observation or use of facilities or equipment, or participation in any program affiliated with the RAC/RCSRA without respect to location, the undersigned, for himself or herself and any personal representatives, heirs and next of kin, hereby acknowledges, agree and represents that he or she has, or immediately upon entering or participating will inspect and consider such premises and facilities or affiliated program.
It is further warranted that such entry into the RAC/RCSRA for observation or use of facilities or equipment or participation in such affiliated program constitutes an acknowledgment that such premises and all facilities and equipment therein and such affiliated programs have been inspected and considered and that the undersigned finds and accepts as being safe and reasonable suited for the purpose of such observations, use, or participation.
IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE RAC/RCSRA FACILITIES, SERVICES, AND PROGRAMS FOR ANY REASON, INCLUDING BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY PROGRAM AFFILIATED WITH THE RAC/RCSRA, WITHOUT RESPECT TO LOCATION, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:
1. The undersigned hereby releases, waives, discharges, and covenants not to sue the RAC/RCSRA, its directors, officers, employees, and agents (the releasees) from all liability to the undersigned, his/her, personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in the death of the undersigned, WHETHER CAUSED BY THE INTENTIONAL NEGLIGENCE OF THE RELEASEES OR OTHERWISE while the undersigned is in, upon, or about the premises or any facilities or equipment therein, or participating in any program affiliated with the RAC/RCSRA, without respect to location.
2. The undersigned hereby agrees to indemnify and save and hold harmless the releasees and each of them from any loss, liability, damage, or cost they may incur due to the presence of the undersigned in, upon, or about the RAC/RCSRA premises or in any way observing or using any facilities or equipment of the RAC/RCSRA or participating in any affiliated with the RAC/RCSRA, WHETHER CAUSED BY THE INTENTIONAL NEGLIGENCE OF THE RELEASEES OR OTHERWISE.
3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR ANY RISK OF BODILY INJURY, DEATH, OR PROPERTY DAMAGE DUE TO THE INTENTIONAL NEGLIGENCE OF RELEASEES OR OTHERWISE while in, about, or upon the premises of the RAC/RCSRA and/or while using the premises or any facilities or equipment therein or participating in any program affiliated with the RAC/RCSRA.
4. The undersigned assumes full responsibility for any lost or stolen items while in, about, or upon the premises of the RAC/RCSRA and/or while using the premises or any facilities or equipment therein or participating in any program affiliated with the RAC/RCSRA.
I further, definitely agree that the foregoing release, waiver, and indemnity agreement cannot be altered in any way, and is intended to be as broad and inclusive as is permitted by the laws of the State of Arkansas and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full force and effect.
I HAVE READ AND VOLUNTARILY SIGN THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, AND FURTHER AGREE THAT NO ORAL REPRESENTATIONS, STATEMENTS, OR INDUCEMENT APART FROM THE FOREGOING WRITTEN AGREEMENT HAVE BEEN MADE.
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WHEN YOU PRESS SUBMIT YOU WILL BE OPENED TO ANOTHER WINDOW THAT WILL WALK YOU TO THE NEXT STEP IN ACTIVENET FOR PAYMENT PROCESSING AND SESSION SELECTION.