RECREATION CENTER WAIVER FORM

Kiwi Kids Interactive Fitness Program Liability Waiver

Participant Information:

• Child’s Name: 
• Date of Birth:
• Parent/Guardian’s Name:
• Contact Number:
• Email Address:

Recreation Center:

Please select the recreation center where your child will attend the program:

• Dimple Dell Recreation Center
• South Jordan Aquatic Center
• Millcreek Community Center

Acknowledgement of Risk and Waiver of Liability:

I, the undersigned, as the parent/guardian of the above-named child, understand that participation in the Kiwi Kids Interactive Fitness Program involves physical activity, which may include, but is not limited to, running, jumping, and other exercises. I recognize that participation in such activities may involve inherent risks, including but not limited to physical injury, and I voluntarily assume all risks associated with my child’s participation.

In consideration of allowing my child to participate in this program, I hereby waive, release, and discharge Kiwi Kids, the above-selected recreation center, Salt Lake City Recreation Centers, and their respective directors, officers, employees, agents, and volunteers from any and all liability, claims, demands, actions, and causes of action arising out of or related to any loss, damage, or injury that may be sustained by my child while participating in this program.

Medical Authorization:

In the event of an emergency, I authorize the program staff to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed necessary for my child’s immediate care and agree that I will be responsible for the payment of any and all medical services rendered.

Photo/Video Release:

I grant Kiwi Kids the right to take photographs and/or videos of my child during the program for promotional purposes, including but not limited to social media, websites, and printed materials.

Parent/Guardian Signature:

• Signature:
• Date:

Emergency Contact Information:

• Emergency Contact Name:
• Relationship to Child:
• Emergency Contact Number:

By signing this waiver, I acknowledge that I have read and understand its content and that I agree to the terms and conditions stated above.