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2. Clean-Up Day

   The Town of Summerville will host a "clean-up day" on Saturday, March 26, 2022, to clear areas of the Sawmill Branch Trail with funds awarded by Palmetto Pride. Clean-up is scheduled for 8 a.m. – 12 p.m. starting at the Luden Dr. access of the trail. Those who wish to participate must register by March 23, 2022. 

4. Gender*

   1. Male

   1. Female
5. Date of Birth*
7. Legal Last Name*
8. Legal First Name*
9. Legal Middle Initial
11. Cell Phone Number:*
12. Email Address
14. Street Address*
16. City*
17. State
18. Zip Code*
22. ***Please fill out if registering a minor***
24. Mother's First Name
25. Mother's Last Name
26. Mother's Cell Phone Number
28. Father's First Name
29. Father's Last Name
30. Father's Phone Number
32. RELEASE OF LIABILITY

    In consideration of providing the opportunity for me and/or my minor child/ward (“my child”), to participate in any way in the Town of Summerville program and related events and activities, the undersigned acknowledges and agrees that, to the extent permitted by law, the following: 

34. 1. I and my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE THE TOWN other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and leasers of premises used to conduct the event (hereafter referred to as “releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to mine or my child’s involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law; and,
36. 2. For myself, spouse, and child, I KNOWINGLY AND FREELY ASSUME ALL RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my child’s participation; and,
38. 3. I willingly agree to comply with the program’s stated and customary terms and conditions for participation, which have been explained to me. If I observe any unusual significant concern in my or my child’s readiness for participation and/or in the program itself, I will remove myself or my child from the participation and bring such attention of the nearest official immediately; and,
40. 4. I and my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.
42. 5. I understand, acknowledge and accept the risk of injury to me or my child from the activities involved in these programs is significant, including the potential for permanent disability and death. While particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury or death does exist.
44. 6. IMAGE RELEASE: I understand and agree that by being allowed to participate in the Town of Summerville's program, related events, and activities, that me and my child’s likeness may be photographed and/or videotaped and that such image(s) may be published in an outlet used to promote or publicize the program unless I indicated my objection below:
46. Check here if you DO NOT want to be photographed and DO NOT consent to the above photo release.

    1. I do not want to be photographed.
48. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.*

    1. yes

    1. no
50. First and Last Name*
    I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
51. Date*
    Date
    I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
55. EMERGENCY INFORMATION AND CONSENT
57. Participant’s First Name*
58. Participant’s Last Name*
60. Address*
62. City*
63. State
64. Zip Code*
66. Emergency Contact*
67. Relationship*
69. Emergency Phone Number*
70. Emergency Phone Number
72. Family Physician Name
73. Phone Number
75. Allergies (List ALL)
77. Medical Conditions
79. I/we hereby grant consent to any and all Health Care Providers designated by the Town of Summerville to provide me or my child any necessary care as result of any injury/illness. This consent includes First aid and transportation to/from Health Care Providers by Emergency Services.*

    1. yes

    1. no
81. First and Last Name*

    I/we hereby grant consent to any and all Health Care Providers designated by the Town of Summerville Parks & Recreation Department to provide me or my child any necessary care as result of any injury/illness. This consent includes First aid and transportation to/from Health Care Providers by Emergency Services.

82. Date*
    Date
    I/we hereby grant consent to any and all Health Care Providers designated by the Town of Summerville Parks & Recreation Department to provide me or my child any necessary care as result of any injury/illness. This consent includes First aid and transportation to/from Health Care Providers by Emergency Services.
84. Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

    The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

     The Town of Summerville has created new protocols and put in place preventative measures to reduce the spread of COVID-19; however, The Town of Summerville cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending any program may increase your child(ren)s risk of contracting COVID-19. By signing this agreement and to the extent permitted by law, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk to which my child(ren) and I may be exposed, or infected by COVID-19 by attending any Town of Summerville program, and that such exposure or infection may result in personal injury, illness, permanent disability, and death.

    I understand that the risk of becoming exposed to or infected by COVID-19 at Town of Summerville programs may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Town employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself including, but not limited to, personal injury, disability, and death, illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my or my child(ren)s attendance of Town of Summerville programs.

    On my behalf, and on behalf of my child(ren)s, I hereby release, covenant not to sue, discharge, and hold harmless The Town of Summerville, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Town of Summerville, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Town of Summerville program. 

86. First and Last Name*
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90. 1. Receive an email copy of this form.
91. Email address

    This field is not part of the form submission.

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