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.

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

Birth Date*
Emergency Contact*

Youth under 18 years

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

The LBC will be hosting an Open House on Thursday, February 12th 11am-1pm. Attend and register to win a $50 LBC gift certificate!