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”).

A. If the Activity is in-person, then I, 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. 

B. If the Activity is virtual (i.e. Phone and Zoom programs), then I, the undersigned, understand, covenant, and agree with the City as follows:

1. The Course and the information provided in it are for educational purposes only.
2. I am entirely responsible to verify whether the information that I receive during the Course is correct or applicable to any use that I choose to make of it.
3. If the Course involves physical activity, then I understand that I am entirely responsible to ensure that I am physically able to participate, have space in which to participate, and to stop participating immediately if I feel any discomfort or adverse health effects.
4. I waive, discharge, adn release any and all claims that I may have against the City, its directors, officers, employees, elected officials, volunteers, and representatives (hereinafter collectively referred to as the "Releasees") arising from my participating in the Course including without limitation, suffering a financial loss arising out of how I apply information received during the Course, or loss of data or damage to any hardware or software that I own from computer viruses. If the Course involves physical activity, then I understand that the scope of this release also incudles but is not limited to injuries from cuts, bruises, broken bones, concussions, strains, tears, permanent disability, heart attacks, or even death which could result from participanting in physical activities.
5. I covenant not to sue the Releasees in regard to any and all claims and liability for any loss, damage, injury or expense that I may suffer arising from My participating in the Course due to any cause whatsoever including negligence, or any duty of care owed to Me by the Releasees.
6. The Releasees cannot guarantee that I will achieve any particular results from using the information obtained during the Course, or that the information provided is or will remain accurate or applicable to My particular circumstances.
7. I hereby indemnify and save the Releasees harmless from any and loss, expense, or damage that Releasees may suffer or incur arising out of My participation in the Course whether arising from the negligence of the Releasees or otherwise to the fullest extent of the law.
8. I understand that this agreement is binding upon Me, My heirs, next kin, executors, administrators, assigns and representatives in the event of My 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.