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2. Participant's First Name*
3. Participant's Middle Name*
4. Participant's Last Name*
6. Gender*

   1. Female
   2. Male
7. Birthdate*
   Birthdate
8. Age*
10. Mailing Address*
12. Physical Address
14. City*
15. State*
16. Zip*
18. Email Address*
20. Primary Phone Number*
21. Secondary Phone Number
23. AGREEMENT, WAIVER AND RELEASE
    In consideration for being permitted by the Town of Mammoth Lakes (“Town”) to participate in the 2021 Adult Programs & Leagues (the “Activity”), I hereby release, discharge and agree not to sue the Town of Mammoth Lakes or any Town employee or official for any personal injury, death, communicable diseases, illnesses, viruses or damage to or loss of personal property arising out of, or in connection with, my participation in the Activity from whatever cause, including the active or passive negligence of the Town of Mammoth Lakes and/or its employees or officials, or any other participants in the Activity. The parties to this agreement understand that this document is not intended to release any party from any act or omission of “gross negligence,” as that term is used in applicable case law and/or statutory provision. I hereby acknowledge that I am voluntarily participating in the Activity and agree to assume any such risks. Activity(ies) include all Town published recreational programs.
25. I,
26. Partipant's Full Name*
28. , fully understand that my participation in the Activity exposes me to the risk of personal injury, death or property damage. I hereby acknowledge that I am voluntarily participating in the Activity and agree to assume any such risks. Activity(ies) include all Town published recreational programs. In consideration for being permitted to participate in the Activity, I hereby agree, for myself and my heirs, administrators, executors and assigns, that I shall indemnify, defend, and hold harmless the Town of Mammoth Lakes and its employees and officials from any and all claims, demands actions or suits arising out of or in connection with my participation in the Activity. I HAVE CAREFULLY READ THIS RELEASE, HOLD HARMLESS AND AGREEMENT NOT TO SUE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT IT IS A FULL RELEASE OF ALL LIABILITY AND SIGN IT OF MY OWN FREE WILL.
30. Participant's Full Name*
31. Date*
    Date
33. IMAGE RELEASE
35. I,
36. Full Name*
38. , hereby consent to allow the exclusive use of, and relinquish all rights to, photographs and video in any manner including the likeness and/or activities of the participant and further authorize the Town of Mammoth Lakes, its agents or assigns, to make unlimited use of such reproductions, including but not limited to print and/or electronically on the internet with or without your name for any lawful purpose. I acknowledge that no compensation will be provided for such use by the Town of Mammoth Lakes. I understand that this Release shall remain in effect unless a subsequent written notification is provided to the Town of Mammoth Lakes.
40. Participant's Full Name*
41. Date*
    Date
43. PERSON TO CONTACT IN AN EMERGENCY
45. Emergency Contact Name*
46. Relation*
48. Address
50. City
51. State
52. Zip
54. Daytime Phone Number*
55. Evening Phone Number
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59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

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