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2. Name*

   Full Name

3. Email Address*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*

    Format: (XXX) XXX-XXXX

13. Liability Waiver The Shelbyville Parks and Recreation Department

    Participant Agreement: I understand the dangers associated with participating in this program or any other physical fitness or recreation program. I am in good physical health and will abide by the rules, regulations, guidelines, and instructions as determined by the Shelbyville Parks and Recreation Department board, directors, instructors, and/or employees.

    Liability Agreement: I do hereby release and hold harmless the City of Shelbyville, Shelbyville Parks and Recreation Department, Shelbyville Central Schools, and any sponsors or associations related to any program or activity, and/or employees liable or responsible for any injuries, claims, and/or damages occurring during my participation in any such sponsored events, programs or activities. This agreement to release and hold harmless shall also be for my heirs, estate, executor, administrator, assignees, and for all members of my family.

15. Electronic Signature*
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17. 1. Receive an email copy of this form.
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