Form Center

2. Agreement and Release of Liability
4. Name*
5. Email Address*
6. Phone Number*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Minor Child(ren) (If applicable):
16. Name
17. Date of Birth
19. Name
20. Date of Birth
22. Name
23. Date of Birth
25. Emergency Contact
27. Emergency Contact Name*
28. Emergency Contact Phone Number*
30. Emergency Contact Email
32. RELEASE OF LIABILITY: In consideration for myself and/or my minor child(ren) being permitted by the City of Coronado (“City”) to participate in recreational activities and/or use City facilities, I hereby waive, release and discharge any and all claims and damages for personal injury, death, or property damage which I, or my minor child(ren), may sustain or which may occur as a result of my participation, or my minor child(ren)’s participation, in these activities or use of City facilities.
34. Check box to agree*

    1. I Agree
36. I understand and agree that: (a) recreational and fitness activities and use of City facilities (cumulatively “recreational activities”) have inherent risks, dangers, and hazards and such exists in my use, and/or my minor child(ren)’s use, of any equipment and my participation in these activities; (b) my participation, and/or my minor child(ren)’s participation, in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death, or other ailments that could cause serious disability; (c) City facilities are open and generally accessible to members of the public; (d) my and/or my minor child(ren)’s and/or other users access to City facilities and/or placement, storage or accessing of property left in City facilities puts such property at a risk of damage, destruction, loss, theft, fire or other casualty; (e) these risks and dangers may be caused by the negligence of the representatives, employees, or volunteers of the City of Coronado, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes; and (f) by my participation, and/or my minor child(ren)’s participation, in recreational activities and/or use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or conduct of the representatives, employees, or volunteers of the City of Coronado.
38. Check box to agree*

    1. I Agree
40. My participation, or my minor child(ren)’s participation, in recreational activities may occasionally result in injury, death or property damage. Knowing the risk involved, nevertheless, I voluntarily request permission for myself or minor child(ren) to participate in the recreational activity. As lawful consideration for permission to enter City property and/or City facilities for any purpose, including but not limited to observation, use of facilities or equipment, leaving or storage of property, or participation in any way, I agree to release from any legal liability to me or to my personal representatives, assigns, heirs, and next of kin, and agree not to sue the City of Coronado, its elected and appointed officers, agents, representatives, volunteers and employees (the “Releasees”), for any loss or damage, including all injuries, death, or property damage caused by or resulting from any use of City facilities, or participation in, or observation of, recreational activities, whether or not such injury, death, or property damage was caused by alleged negligence of the Releasees, or any of them.
42. Check box to agree*

    1. I Agree
44. To the maximum extent permissible by law, this release is intended to discharge in advance the City, its officers, employees and agents from and against any and all liability connected in any way with my participation, or my minor child(ren)’s participation, in recreational activities or any use of City facilities. I agree to indemnify, defend (with counsel acceptable to City), and hold harmless the Releasees, from any and all claims asserted or liability established for damages or injuries to any person or property, that arise out of or are in any manner directly or indirectly connected with my use of City facilities or participation in recreational activities, and all expenses of investigating and defending against the same, including any claims or liability arising from the active negligence of the Releasees unless otherwise prohibited by law.
46. Check box to agree*

    1. I Agree
48. I hereby acknowledge and agree that participation in recreational activities and the use of City of Coronado property, services, facilities, programs, classes, or other sponsored recreational activities has inherent risks. Those risks include, but are not limited to, all manner of injury resulting from negligent misuse of City facilities or equipment; falling off and/or impacting against City property, facilities, equipment, projections (permanently or temporarily in place), and floor; slips, trips, falls, or other, in using City facilities or equipment; negligence or intentionally wrongful conduct of other participants, visitors, or persons who may be present during the recreational activities.
50. Check box to agree*

    1. I Agree
52. I also hereby acknowledge and agree that certain recreational activities, like use of a skatepark, are hazardous and creates a substantial risk of injury to myself and/or my minor child(ren). I agree, represent and warrant that I and my minor child(ren) are twelve (12) years of age and will wear a commercially manufactured helmet, elbow pads and knee pads at all times while using the skatepark. I understand and acknowledge that despite the use of such protective gear, using the skatepark could result in injury, death or property damage.
54. Check box to agree*

    1. I Agree
56. I further recognize the inherent risks of damage to, or loss of, any property associated with my use of City facilities, arising from any cause whatsoever, whether foreseeable or not, including, but not limited to: fire, theft, vandalism, water damage, mysterious disappearance, rodents, acts of god, disease, pandemic or the active or passive acts or omission or negligence of the Releasees or any third party.
58. Check box to agree*

    1. I Agree
60. I hereby assume any and all risks of injury, death, or property damage and, on behalf of myself and/or my minor child(ren), release and hold harmless the Releasees, excepting only loss, injury, damage or costs that arise out of the City’s intentional wrongful acts or violations of law. I further agree and understand that all of my rights against the City under Section 1542 of the Civil Code of the State of California and any similar law of any state or territory of the United States hereby expressly waive such rights. Section 1542 reads as follows: “A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER, WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY.”
62. Check box to agree*

    1. I Agree
64. I agree to be responsible to follow, and ensure that my minor child(ren) follow, any safety rules and procedures established by the City of Coronado in connection with recreational activities.
66. Check box to agree*

    1. I Agree
68. I hereby acknowledge, agree, and represent that I have, or immediately upon entering, will inspect the facility, equipment, and the surrounding premises, and I further warrant that my participation in recreational activities, including but not limited to participation, observation, or use of facilities or equipment, constitutes an acknowledgement that such premises and all facilities and equipment thereon have been inspected and that the undersigned finds and accepts the same as being safe and reasonably suited for the purposes of such observation or use.
70. Check box to agree*

    1. I Agree
72. I acknowledge that novel coronavirus SARS-CoV-2, also known as COVID-19 (hereinafter ''COVID-19") infections have been confirmed throughout the United States. In accordance with the most recent guidance and protocols issued by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and the California Department of Health for slowing the transmission of COVID-19, I hereby agree, represent, and warrant that neither I nor my minor child(ren) shall visit or use the facilities, services, and programs of the City (other than any exclusively online services and programs) within 14 days after (a) returning from highly impacted areas subject to a CDC Level 3 Travel Health Notice, (b) exposure to any person returning from areas subject to a CDC Level 3 Travel Health Notice, or (c) exposure to any person who has a suspected or confirmed case of COVID-19. The CDC Travel Health Network is continuously updating this list and I agree that I am aware of this list and the countries listed.
74. Check box to agree*

    1. I Agree
76. I agree to check the CDC Travel Health Notices list (https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html) prior to using the facilities, services, and programs of the City, on a daily basis if necessary. I hereby agree, represent, and warrant that neither I nor my minor child(ren) shall visit or use the facilities, services, and programs of the City if I, or my minor child(ren), (a) experience symptoms of COVID-19, including, without limitation, fever, cough, or shortness of breath, or (b) have a suspected, diagnosed, or confirmed case of COVID-19. I agree to notify City staff immediately if I believe that any of the foregoing access or use restrictions may apply.
78. Check box to agree*

    1. I Agree
80. The City has taken certain steps to implement recommended guidance and protocols issued by the Public Health Agencies for slowing the transmission of COVID-19, including, without limitation, the access and use restrictions set forth above. I acknowledge and agree that the City may revise its procedures at any time based on updated recommended guidance and protocols issued by the Public Health Agencies and further agree to comply with the City’s revised procedures prior to using the facilities, services, and programs. I further acknowledge and agree that, due to the nature of the facilities, services, and programs offered by the City, social distancing of six (6) feet per person among participants and staff is not always possible. I fully understand and appreciate both the known and potential dangers of utilizing the facilities, services, and programs of the City and acknowledge that use thereof by myself and/or my minor child(ren) may, despite the City’s reasonable efforts to mitigate such dangers, result in exposure to COVID-19, which could result in quarantine requirements, serious illness, disability, and/or death.
82. Check box to agree*

    1. I Agree
84. I agree that this AGREEMENT AND RELEASE OF LIABILITY is intended to be as broad and inclusive as is permitted by law. Any provision found to be invalid or unenforceable by a court shall not affect the validity or enforceability of any other provision.
86. Check box to agree*

    1. I Agree
88. I am aware that this AGREEMENT AND RELEASE OF LIABILITY is legally binding and that I am releasing legal rights by signing it. This AGREEMENT AND RELEASE OF LIABILITY is binding on my heirs, personal representatives, next of kin, successor, executors and assigns.
90. Check box to agree*

    1. I Agree
92. NAME AND LIKENESS RELEASE: I understand City staff may photograph or videotape me and/or my minor child(ren) while I am, or my minor child(ren) is (are), on or using City property and/or participating in City programs, classes, or other sponsored recreational activities. In further consideration for myself and/or my minor child(ren) being permitted by the City to participate in recreational activities, the City may use my name and likeness, or my minor child(ren)’s name(s) and likeness(es) in connection with my participation in the recreational activities and/or my, or my minor child(ren)’s, use of City property or facilities. I expressly allow the City to photograph or videotape me and/or my minor child(ren) when I, or my minor child(ren), participate in the recreational activities, and I hereby waive any objection to the same. The City may use my, and/or my minor child(ren)’s, name, likeness, or any photographs or videotape of me or my minor child(ren) in connection with the use of City facilities and recreational activities in any City publication, including news releases and/or to promote City programs and classes, without my prior consent. I understand all photographs and videotape will remain the property of the City of Coronado, and further agree that I am, and/or my minor child(ren) is (are), not entitled to compensation for such use.
94. Check box to agree*

    1. I Agree
96. MEDICAL TREATMENT (SELF): In connection with any injury I may sustain, or illness or other medical conditions I may experience, during my participation in recreational activities, I authorize any emergency first aid, medication, medical treatment, or surgery deemed necessary by attending medical personnel if I am not able to act on my own behalf. I understand that I will be responsible for any expenses incurred on my behalf in connection with such treatment.
98. Check box to agree*

    1. I Agree
100. MEDICAL TREATMENT (MINOR CHILD OR CHILDREN): In connection with any injury my minor child(ren) may sustain, or illness or other medical conditions my minor child(ren) may experience, during his or her participation in recreational activities, I, the undersigned parent(s) or legal guardian(s) of the above minor child(ren), do hereby authorize the City and/or any California Hospital as agents for the undersigned to consent, in advance of any specific diagnosis, to any x-ray examination, anesthetic medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any California Hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California, and shall remain effective until revoked in writing by a parent or guardian.
102. Check box to agree*

     1. I Agree
104. CERTIFICATION: I certify that I am the parent of the minor child(ren) named above, or I have custody or am the legal guardian of said minor(s) by court order, if any. I further certify that I am, and my minor child(ren) is (are), physically able to participate in the recreational activities. I have carefully read this AGREEMENT AND RELEASE OF LIABILITY and fully understand its contents. I sign it of my own free will.
106. Check box to agree*

     1. I Agree
108. By typing my full name below, I agree to all terms and conditions.*
109. Date*
     Date
111. Would you like to create a PerfectMind account?*

     1. Yes
     2. No

     Proof of residency and minor's birthdate will still need to be provided for account creation.  Send these documents to [email protected].

     Staff will reach out to you directly if you wish to create a PerfectMind account.

Leave This Blank:


113. 1. Receive an email copy of this form.
114. Email address

     This field is not part of the form submission.

115. Submit

* indicates a required field