Liability Waiver Form
Release of Liability:

I hereby, for myself, my family, heirs, executors and administrators, waive and release any and all
claims and damages I have against the FOOTHILLS AREA YMCA, City of Walhalla, all locations where
YMCA programs are held, including the Walhalla City Pool, and their respective agents,
representatives, successors, and assigns, for any and all injuries which may be suffered by me or my
family in connection with participation in YMCA activities and programs. I also state that myself
and/or my child is in good physical condition and able to participate in YMCA programs. In the event
of an accident – I am aware that the YMCA does not provide accident insurance and will not hold the
YMCA responsible for any injury.

I understand that the FOOTHILLS AREA YMCA nor the City of Walhalla are responsible for lost, stolen,
or damaged private property brought onto pool grounds. I also agree to abide by all pool rules. In the
event that my behavior and/or actions do not align with the pool rules, I may be asked to leave
without reimbursement for any fees paid.

I understand that no alcohol, tobacco products, or illegal drugs are allowed on YMCA property at any

I understand that if my child is under 10 years old, I must remain at the pool while they are here. I understand that any minor under the age of 15 will be required to take a swim test. If such minor
fails the swim test or refuses to take such swim test, they will be required to stay in the shallow end
and/or wear a life jacket and you must remain at the pool while they are on the pool premises.

Name *
Your answer
Signature *
Your answer
Phone Number *
Your answer
Date *
If you are signing for a minor, please list their names below with their ages. (ex. John Doe - 5)
Your answer
If your child is under the age of 10, you MUST remain at the pool while they are here. Please sign below that you understand this statement whether it applies to you or not. *
Your answer
If your child is between the ages of 10 and 14, has passed the swim test, and you would like to allow him/her to swim at the Walhalla City Pool without your supervision, please sign below:
Your answer
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