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Heritage Soccer Park Waiver for Coach's Child - Cubs Kickers

  1. JCPRD logo
  2. This waiver is for anyone who plans to coach their child in the Cubs Kickers program. All information below is required.
  3. CONTACT INFO
  4. Waiver Statement
    WAIVER RELEASE STATEMENT: The undersigned states that he/she understands that the Johnson County Park and Recreation District is not and shall not be responsible for or liable for any illness, injury or death to person or damage to property including but not limited to illness, injury, or death arising from exposure to the Novel Coronavirus (COVID-19), resulting from the program in which the undersigned is enrolling or being enrolled or from his/her participating in said program, and the participant and the undersigned, if the participant is a minor or under other legal disability, hereby forever releases and holds harmless the said Johnson County Park and Recreation District, its employees, agents and representatives from any and all claims of any kind, including but not limited to claims arising from exposure to the Novel Coronavirus (COVID-19), that the participant, or the undersigned or their respective heirs, executors, administrators, or assigns may have or claim to have resulting from participation in said program. NOTICE: By participating in this program you hereby acknowledge the Johnson County Park & Recreation District can and may photograph and/or video tape program participants and then use such images, without payment or any other consideration, for purposes of publicizing District parks, facilities, programs or services, or for any other lawful purpose.
  5. Electronic Signature Agreement*
    By checking the "I agree" box below, you agree and acknowledge that 1) your waiver form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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  7. This field is not part of the form submission.