Release of Liability

By my signature below, I signify that I have read, understand, and voluntarily agree to the following:

All patrons interested in participating in the use of the facility or programs must present one current form of picture identification (ID) such as a driver’s license, state ID cars, student ID, etc.

In consideration of the Lester Buresh Family Community Wellness Center granting the participant permission to participate in activities/programs, I hereby assume all risks of personal injury (including death) and property damage that may result from any activity/program. I do hereby release and agree to indemnify, defend, and hold harmless the Lester Buresh Family Community Wellness Center, the City of Mount Vernon, their employees, officials, agents, and volunteers, present and future, and all participants in the program/activity from and against all liability, including claims and suits at law or in equity, for damages or injuries, fatal or otherwise, know or later discovered, which may result from any negligence or the participant taking part in activities/programs offered by the Lester Buresh Family Community Wellness Center at any location that these activities may take place.

  • Youth under 11 must be directly supervised by someone who is at least 16 years old.
  • Youth under 16 are not allowed in the Fitness Hallway or Studio.
  • Youth 14-15 can use these areas with Weight Training Certification.
  • Youth 12-13 can use these areas with Weight Training Certification and a parent/guardian.
  • The Climbing Wall is available during scheduled staff hours.
  • The use of facilities and amenities are to be used as a shared space. The LBC reserves the right to restrict full court play and batting cage use based on availability.
  • Personal items are to be stored in the locker rooms or cubbies. Personal items should not be left unattended, place on the floor, or on equipment.
  • Use of cell phones and camera/video devices are prohibited in the locker rooms. 
  • All photography, videotaping, etc. within the LBC must be pre-approved by Administration.
  • The LBC is a substance free facility, prohibiting alcohol, illegal drugs, and tobacco including smokeless tobacco and e-cigarettes.
  • Shirts and shoes are required at all times.
  • Non-marking , clean, closed-toe athletic shoes must be worn on basketball courts, fitness studio and climbing wall. 
  • Use of the LBC is a privilege. Disciplinary action will be enforced against patrons involved in any use of theft, bullying, fighting or disrespectful actions among patrons, toward staff, and to the facility.
  • I give my permission to use photographs of me and/or the members in my family for advertising and publicity purposes.

Warning of Risk: Aerobic and other fitness exercises including such items as passive/resistive weight training, use of stair climbers, treadmills, and other training devices, despite careful and proper preparation, instruction, medical advice, conditioning and equipment, pose a substantial risk of injury. You are responsible for determining if you are physically fit for these activities. It is advisable to consult a physician before undertaking any physical exercise program.

Release of Liability Form

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Adults 18 years of age and older

Name*
Birth Date*
Address*
Emergency Contact*
Clear Signature
Date*

Youth under 18 years

Family Release of Liability (children under the age of 18)
Name
Birth Date
Name
Birth Date
Name
Birth Date
Name
Birth Date
Clear Signature
Date

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