2021 Program Waiver Form

Please complete the information on the form. Please ensure you sign the waiver form. A waiver is required before participating in recreation programs.

STOP. This waiver is an important legal document. Read it carefully. Signing this waiver is a condition of participating in the recreation program you have signed up for (the “Activity”), which is being offered by the City of Belleville (the “City”).

I, the undersigned, understand, covenant, and agree with the City as follows:

1. Participating in the Activity brings with it an increased risk of cuts & bruises, broken bones, concussions, permanent disability or even death which could result from slips, falls, contact with other participants, misuse of equipment or other types of accidents associated with the Activity.
2. Participating in the Activity also brings with it an increased risk of illness from bacteria, viruses such as Covid-19, or other communicable diseases which may be contracted through touching high traffic areas and equipment, being in proximity to other Activity participants or City staff, and I understand that such infection could also result in serious illness, disability, permanent loss of function, or even death.
3. I hereby waive, discharge, and release any and all claims that I or my child, may have against the City, its directors, officers, employees, elected officials, volunteers and representatives (the "Releasees") arising from my or my child’s participation in the Activity, including without limitation, injury arising out of those risks noted above. I covenant not to sue the Releasees directly or on behalf of my child, in regard to any loss, damage, injury or expense that I or my child may suffer arising from participating in the Activity including illness or death, due to any cause whatsoever including negligence or any duty of care owed to me or my child by the Releasees.
4. This agreement is binding upon me, my child, my heirs, next of kin, executors, administrators, assigns and representatives in the event of my or my child’s death or incapacity. 

By signing my name below, I declare to the City that: (1) I am assuming all the risks associated with  my or my child participating in the Activity; (2) I am giving up my right and my child’s right to sue the City for any and all damages that may arise out of my or my child participating in the Activity; (3) I am my child’s parent or legal guardian (if applicable).

Notice of Collection

All information including Personal Information, collected by the CIty of Belleville is done so under the authority of the Municipal Act, 2001 and the Municipal Freedom of Information and Protection of Privacy Act, each as amended and will be used for the administration purposes of the City of Belleville's recreation programs and facilities and wellness passport program. Questions about the collection of this personal information should be directed to: City Clerk, 169 Front Street, Belleville ON K8N 2Y8, Telephone: 613-968-6481.