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2. Contact Information
4. Participant Name:
6. First Name*
7. Last Name*
8. Birthday :
10. Street Address*
11. Phone Number:
13. City*
14. State*
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15. Zip Code*
17. Email:
19. Emergency Contact Information
21. Emergency Contact:
22. Phone:
23. Relationship:

25. As a participant, I am aware certain risks are inherent in the above activities. I hereby acknowledge that I am voluntarily participating in this program and agree to assume such risks. Nevertheless, to gain the City of Modesto’s permission to participate, by signing this document, I am relieving the City of Modesto, its management and employees from liability, and save them harm from any claims I may have for personal injury, property damage or wrongful death caused by their negligence. I agree to allow usage of my photograph, or other recording, by the City of Modesto for any purpose without obligation or liability to me.

    By signing this waiver to participate in City of Modesto Parks, Recreation and Neighborhoods Department program, I understand that I am expected to comply with all measures outlined by the State of California Governor’s office as outlined at www.COVID.CA.GOV , as well as any restrictions put in place by  the Stanislaus County Health Services Agency as they pertain to safety and preparedness for COVID-19. All participants are encouraged to stay home should they have any fever or other COVID-19 symptoms. Participants must comply with all state and local social distancing requirements, including wearing a mask, in effect at the time of the activity. Higher risk individuals over the age of 65 or individuals with underlying medical conditions should not participate in or attend this program. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by participating in this program, and I hold the City harmless from any and all COVID-19 related liability or responsibility due to my participation in this program.  

27. Signature:
28. Date:
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30. 1. Receive an email copy of this form.
31. Email address

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32. Submit

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