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Hampshire Regional YMCA

Adult Participant Waiver

Adult Participant Waiver, Release, Indemnification of All Claims & Covenant Not to Sue

NOTICE:  THIS IS A LEGALLY BINDING AGREEMENT. Read this document carefully and in entirety. By signing this agreement, you give up your right to bring a court action to recover compensation or obtain any other remedy for any personal injury or property damage however caused arising out of your participation in Hampshire Regional YMCA Programs, now or at any time in the future.

Acknowledgment of Risk

I hereby acknowledge and agree that participation in Hampshire Regional YMCA activities comes with inherent risks. I have full knowledge and understanding of the inherent risks associated with Hampshire Regional YMCA participation, including but in no way limited to: (1) slips, trips, and falls, (2) aquatic injuries, (3) athletic injuries, and (4) illness, including exposure to and infection with viruses or bacteria. I further acknowledge that the preceding list is not inclusive of all possible risks associated with Hampshire Regional YMCA participation and that said list in no way limits the operation of this Agreement.

Coronavirus / COVID-19 Warning & Disclaimer

Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a mean to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in Hampshire Regional YMCA programs or accessing Hampshire Regional YMCA] facilities could increase the risk of contracting COVID-19. Hampshire Regional YMCA in no way warrants that COVID-19 infection will not occur through participation in Hampshire Regional YMCA programs of accessing Hampshire Regional YMCA facilities.

Waiver, Release, Indemnification & Covenant Not to Sue

In consideration of my participation in Hampshire Regional YMCA , I, __________________________, the undersigned participant, agree to release and on behalf of myself, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE Hampshire Regional YMCA its officers, directors, employees, volunteers, agents, representatives and insurers (“Releasees”) from any causes of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I, my heirs, representatives, executors, administrators and assigns may have, now or in the future, against Hampshire Regional YMCA on account of personal injury, property damage, death or accident of any kind, arising out of or in any way related to the use of Hampshire Regional YMCA facilities/equipment or participation in Hampshire Regional YMCA  programs whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to the negligence of Releasees.

In consideration of my participation in Hampshire Regional YMCA , I, the undersigned participant, agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, or costs of any nature whatsoever arising out of or in any way related to my Hampshire Regional YMCA  participation.

I hereby certify that I have full knowledge of the nature and extent of the risks inherent in Hampshire Regional YMCA  participation and that I am voluntarily assuming said risks.  I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, or death, I sustain while participating in Hampshire Regional YMCA and that by signing this agreement I HEREBY RELEASE Releasees from all liability for such loss, damage, or death. I further certify that I am in good health and that I have no conditions or impairments which would preclude my safe participation in Hampshire Regional YMCA .

I further certify that my date of birth is _____________ (MM/DD/YYYY), that my present age is ______, and that I am therefore of lawful age and otherwise legally competent to sign this agreement.  I further understand that the terms of this agreement are legally binding and certify that I am signing this agreement, after having carefully read it, of my own free will.

IN WITNESS WHEREOF, this instrument is duly executed this _____ day of ____________________, in the year ________.


____________________________               _________________________                    _____________

Participant Signature                        Participant Name (Print Clearly)                   Member ID#



    Member Information





    Date of Birth*

    Member Information




    Phone 2





    Emergency Contact Name*

    Emergency Contact Phone*

    Liability Waiver Statement

    I certify that I am at least 18 years of age and I have read, understand, and voluntarily accept the terms of this Agreement and further agree that no oral representations, statements or inducement apart from the foregoing Agreement have been made.

    I certify that I am the parent and/or legal guardian of (the minor) who is currently under the age of 18.

    I agree to release the National Council of Young Men’s Christian Associations of the United States of America, and its independent and autonomous member associations in the United States and Puerto Rico, from claims of negligence for bodily injury or death in connection with the use of YMCA facilities, and from any liability for other claims, including loss of property, to the fullest extent of the law.

    By checking this box and retyping my name below, I am electronically signing this form.

    Parent/Guardian Name*