Date *
Date
Name *
Name
Phone *
Phone
Place of residence *
Liability Waiver *
I accept full responsibility for my use of any and all equipment, facility privilege or service whatsoever, owned and operated by this Club at my own risk and shall hold this Club, its shareholders, directors, landlords, officers, employees, representatives and agents harmless from any and all loss, claim, injury, damage or liability sustained or incurred by me resulting therefrom.