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New Century Fieldhouse Open Gym Waiver Form

  1. JCPRD logo
  2. This waiver is for children (ages 13 and up) participating in open gym who are not attending with their parent/guardian. Please provide a separate form for each child under the age of 18. The child must have a current waiver on file or be accompanied by their parent or guardian to participate. Waiver must be submitted at least 24 hours prior to participation in open gym. If participating with less than 24 hours notice, then a paper waiver must be turned in at time of check in.
  3. Please note: Children 12 and younger must be accompanied by an adult age 18 or older.
  5. Waiver Statement

    The undersigned states that he/she understands that the Johnson County Park & 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 pro-gram 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 & Recreation District, it's employees, agents and representatives from any and all claims of any kind, including but not limited to claims arising from exposure to the Novel Corona-virus (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 enrolling in this pro-gram you hereby acknowledge the Johnson County Park & Recreation District can and may photograph and/or vid-eo 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.



  6. 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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  8. This field is not part of the form submission.