Pare

ntal S

tate

ment of A

greement – A

ssumptio

n of Risk, L

iability

Release

, Ind

emnifica

tion a

nd R

efund

Policy

1. Rele

ase and

Ind

em

nification: I

here

by re

cognize

and ack

nowle

dge

that m

y child

’s participation in recre

ational activitie

s may involve

bod

ily injury and/o

r em

otional injury

to myse

lf and/o

r my ch

ild. I

n consideration o

f my ch

ild b

eing

perm

itted to participate

in such e

vents, I

for m

yself, m

y child

, my h

eirs, m

y executors and

adm

inistrators,

herb

y voluntarily and k

nowingly ind

em

nify and h

old h

armle

ss, defe

nd, re

lease

, waive

, and d

ischarge

Salt L

ake C

ounty, and

its officers, e

mploye

es and

volunteers from

any and

all suits, claims o

r liability, includ

ing ne

gligence

, base

d on any injury e

xce

pt that cause

d sole

ly by th

e w

illful miscond

uct of S

alt Lake

County, th

at may re

sult from m

y child

’s

participation in Salt L

ake C

ounty Parks &

Recre

ation activities. I

n additio

n, I ag

ree th

at I o

r my insurance

company w

ill pay fo

r medical, h

ospitalization or any other e

xpe

ns-

es re

sulting from m

y child

’s

participation.

2. R

efund

Policy: As pe

r Salt L

ake C

ounty policy and p

rocedure

s, the Parks &

Recre

ation Division m

ay with

hold

25

% o

f the re

fund (p

rogram

registration fe

e) fo

r adm

inis-

trative costs. A

ll refund

s must b

e re

queste

d in pe

rson, accompanie

d w

ith a w

ritten re

fund re

quest. N

o refund

s shall b

e give

n after th

e first d

ay of the p

rogram.

3. C

ollections: I

agre

e to

pay Salt L

ake C

ounty all costs incurred toge

ther w

ith re

asonable

attorne

y’s fees in th

e e

vent th

at my account is

refe

rred

to the S

alt Lake

County

Attorne

y’s Office

for colle

ction. I

understand

that any account d

elinque

nt 30

days o

r more

will b

e turne

d ove

r to the S

alt Lake

County A

ttorne

y for collection.

4. E

merge

ncy Tre

atment: I

here

by auth

orize S

alt Lake

County Park

s and R

ecre

ation prog

ram staff to act on m

y behalf in acco

rdance

with

their b

est ju

dgm

ent in case

of an

em

erge

ncy involving my ch

ild, and

agre

e to assum

e full re

sponsibility fo

r all expe

nses, m

ed

ical or oth

erw

ise, th

at may arise

there

from. I

understand

that I

or my insurance

company w

ill pay for such

em

erge

ncy treatm

ent.

5. E

qual Oppo

rtunity: Salt L

ake C

ounty Parks and R

ecre

ation provid

es e

qual opportunity to participate re

gardle

ss of race

, creed, ge

nder, o

r ability to pay, and

will, upon

reque

st, provid

e re

asonable

accomm

odations to

individ

uals with

disab

ilities.

6. B

y signing th

is assumption of risk

, liability re

lease

, indem

nification and re

fund policy state

ment, I

acknow

ledge

that I

have

read

its conte

nts and d

isclosure, th

at I un-

derstand

its contents and

disclosure

, and th

at I ag

ree to

its term

s.

Signa

ture (if und

er 1

8 Pa

rent or L

ega

l Gua

rdian) _

______________________________________________________

Date________________

(Ple

ase w

rite c

learly

)

Nam

e of Participant__

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_B

irth d

ate__

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ge_

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irl __

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_B

oy__

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Address_

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City_

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tate_

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Zip_

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Sch

ool Atte

nding_

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rade_

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Parent or Guard

ian__

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Best E

mail A

ddre

ss__

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Hom

e Phone_

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CellPh

one_

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Em

ergency C

ontact (other th

an guardian)_

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_Ph

one_

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I would

like to be placed

on the sam

e team

as__

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Copperview Recreation Center

8446 S. Harrison St. (300 W.) Midvale, UT 84047

(801) 559-1500

OFFICE U

SE O

NLY

…R

eceipt No. _

__

__

__

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_ A

mt. $

__

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_ R

ecv’d

. by _

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_

D

ate__

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Cod

e of Cond

uct __

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_ I

nformation S

heet _

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_

Who: Boys and Girls Co-ed League

(T-Ball 3-5 year olds, Coach Pitch 6-7 year olds)

Games: All Games will be played at Copperview Recreation

Center Softball fields

Games will be played Saturdays from 9:00AM-3:00PM

Program includes: Hat, shirt, 8 games, participation award, and 2 bees ticket vouchers

Cost: $31

What: Taken from the story of the “Hunger Games’”, this camp will

teach you everything from strategy to outdoor survivial. Come join

other youth and have a BLAST learning about animal tracks, building

shelters, geochaching & more! All while competing with other

“districts” in a fun & exciting adventure.

Who: Boys and Girls, 4th– 7th Grade

Where: Copperview Rec. Center

When: Monday April 2nd- Friday April 9th, 9:00am—12:00pm

Cost: $75

SIGN UP EARLY! SPACE IS LIMITIED

Katniss’ Challenge: Survivor Camp

Who: Boys and Girls, ages 5-12 years old

When: Starts Monday April 2nd—Ends Friday April 6th

Times: Drop-off 8:15 a.m.—Pick-up no later then 6:00 p.m. ($5 late pick-up fee will be enforced after 6pm)

Fee: $55

Lunch WILL NOT be provided! AM & PM Snacks will be provided

ACTIVITIES WILL INCLUDE: Swimming Field Trip, Sports and Fitness, Arts and crafts, Games, and lots of other fun activities!

You must register in advance! Space is limited!

I am signing m

y child

up for: (only one activity per registration sh

eet)

Socce

r

Tee B

all/C

oach

Pitch

Spring B

reak C

amp S

urvivor Camp

□ Pre-K

(ages 3

-4) □

Tee B

all (ages 3-5

)

□ 5

-9 years old

□ 8

-10 ye

ars old

□ K

indergarte

n □

Coach

Pitch(age

s 6-8

)

□

8-12

years old

□ 11-13

years old

□ 1st-2

nd G

rade

□ 3

rd-4

th G

rade

□ 5

th-6

th G

rade

I would

like to coach: N

AM

E:_

_______________________________________ Ph

one #

___________________________

Best E

mail A

ddre

ss______________________________________________

What: Outdoor recreation soccer program where fun & skills are the main focus.

Who: Boys and Girls Pre-K thru 6th grades (5th and 6th grades will be a traveling team with in Midvale and Sandy)

Where: Midvale City Park/ Copperview Elem./ Copperview Recreation Center

When: PreK thru 2nd grade Wednesday evenings & Saturday mornings. 3rd thru 6 grades Tuesday evenings & Saturdays Organization Day is April 14th

Program includes: Full Uniform (jersey, shorts, socks) 8-games & participation award

Cost: $36 full fee (Prek-2nd) $41*(3-6 grades)

Become a SL County Certified Coach to receive$25 Discount

For more information please visit our website www.recreation.slco.org/copperview click on Youth Sports or

call the coordinator @ (801) 559-1500