Name and Signature of Adult Household Member Completing this Application

I certify that the information provided on this application is accurate.

Please Provide Complete Information for each Resident of your Household

Waiver and Release and Assumption of Liability

I, the undersigned, as a participant (the “Participant”)* using the swimming pool, fitness facilities and equipment, and other services of the Jerome Village Community Center (the “Activity”) understand that there are certain inherent risks associated with participating in the Activity. In consideration for my participation in the Activity, I, on behalf of myself, my representatives, heirs, and assigns, do hereby release and waive and agree to hold the Jerome Village Community Authority and its Board of Trustees, the manager of the Community Center, Jerome Village Company, LLC, and their respective members, officers, employees, and agents, harmless from any and all claims, liabilities, causes of actions, or damages arising from, resulting from, or in any way related to any injury, death, loss or damage of whatever nature or description to person or property, including theft or other intentional actions of third parties, resulting from my participation in the Activity. I do hereby assume all risks related to such participation. I acknowledge that I am participating in the Activity voluntarily. I agree that this Waiver and Release and Assumption of Liability shall be binding upon my successors, representatives, estate, heirs and next of kin.

By signing below you acknowledge that you have received and read all the “Rules and Regulations” for the Jerome Village Community Center.

PARENT OR GUARDIAN MUST SIGN IF PARTICIPANT IS UNDER 18:

As the parent or legal guardian of each of the minors listed below, I hereby agree to this Waiver and Release and Assumption of Liability for, and on behalf of, each of the minor individuals listed below. In addition, I hereby authorize and give consent to each of the minor individuals indicated with a “Yes” below to use the swimming pool at the Community Center without parental or guardian supervision and acknowledge and confirm that each such minor individual is 12 years of age or older. Furthermore, I hereby authorize and give consent to each of the minor individuals indicated with a “Yes” below to use the fitness facility at the Community Center without parental or guardian supervision and acknowledge and confirm that each such minor individual is 14 years of age or older.