LML Exercise Waiver

First

Last

Phone Number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Emergency Contact Name

Emergency Contact Phone Number

Please select the program(s) you will be attending

What age group is this program for?

Adult

Teen

Children

When submitting this form you must agree to the following:

I acknowledge that I am voluntarily participating in a physical activity/program sponsored by the Lindenhurst Memorial Library.

I assume all risks associated with this type of physical activity/program, and I waive any right I may have to a claim or claims against the library for personal injury or property damaged sustained by me, by any cause whatsoever.

I further agree to indemnify and hold harmless the library for an injury to persons or property caused by me while participating in this activity.

I will consult with my physician before beginning this physical activity/program.