Name *

First Name

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Address

Address 1

Address 2

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Agreement *

I, as the of Participant, Parent/Legal Guardian of Minor Participant, Do herby indemnify, save, defend, hold harmless, release, and forever discharge UEmpower of Maryland, it’s employees, instructors and volunteers, from any and all, present and future liability, demands, suits, actions, or claims for losses, damages, or injury, including death, sustained by the participant arising from the participant’s participation in any related city programs, activities, trips, and excursions, regardless of whether such claims, losses, damages or injuries result, in whole or part, from the negligence of the of UEmpower of Maryland, it’s employees, instructors and volunteers. This provision shall survive termination of this release and authorization. I have read and fully understand the above waiver and release of all claims. If registering on-line or via fax, my on-line or facsimile signature shall substitute for and have the same legal effect as an original form signature. By checking the box below, I as the Participant or Parent / Legal Guardian of the Participant, acknowledge and agree to the above.

I Agree