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2. Student's Name:*
3. Age:*
4. Grade:*
6. School Name:*
8. Parent/Guardian Name(s):*
10. Phone Number:*
11. Home Address:*
13. Food Allergies (if none, enter " n/a "):*
15. Emergency contact (other than parent who is local):*
16. Emergency Contact Phone:*
20. City Gym Rules

    Review these rules with your student prior to attending:

    • No alcohol, smoking, illegal drugs, weapons, or vandalizing.
    • No improper behavior, gestures, or language.
    • No food or beverages on the gym floor or racquetball court.
    • No black-marking shoes on the court.
    • No unsportsmanlike conduct will be tolerated.

    Any person who misuses the City Gym facilities or equipment engages in misconduct on or about the facilities or engages in conduct disruptive to programs being held at the facilities, whether or not in connection with an event sponsored by the Parks Department, shall be subject to having their City Gym privileges revoked at the sole discretion of the Superintendent of the Parks Department for the City of Bluffton.

    Open gym is typically from 3:30-6 pm every Monday, Thursday, Saturday, and Sunday, November – mid-March. Gym calendars are posted on the City Gym TeamUp Calendar. 

    This supervised gym time is for students in K-12th grade only. Adults are not allowed on the gym floor and may not coach their children from the stands. Please pick up your child promptly by 6 pm.

24. Waiver and Release from Liability

    On behalf of myself, my executors, administrators, heirs, next of kin, successors and assigns, HEREBY WAIVE, RELEASE AND DISCHARGE from any and all claims or liabilities for death, personal injury, property damage, theft or damages of any kind, whether or not attributable to the negligence of the releasees, the City of Bluffton, the Mayor of Bluffton, the Common Council of the City of Bluffton, the Bluffton Board of Public Works and Safety and any agents, successors, assigns or employees of any of the foregoing which may arise out of my child’s participation in open gym and the use of the Bluffton City Gym and equipment.

    I HEREBY AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims or liabilities that I have waived, released or discharged herein.

    I AGREE TO INDEMNIFY AND HOLD HARMLESS the City or any person or entity mentioned above from and against any and all damages, losses, liabilities, obligations, penalties, claims, litigation, demands, defenses, judgments, suits, proceedings, cost, disbursements or expenses of any kind or nature whatsoever (including, without limitation, attorney’s fees and experts fees and disbursements) which may at any time be imposed upon, incurred by or asserted or awarded against an of the releasees identified above which relates to or in any way arises out of my acts or omissions in connection with the use of the volleyball stands.

    I HEREBY AFFIRM that I am 18 years of age or older and that I have read and understand the foregoing.

26. Date:*
    Date:
28. Parent/Guardian Digital Signature:*
30. Student Digital Signature:*
32. Information Consent*

    1. I consent to the City of Bluffton, Indiana storing my submitted information so they can respond to my inquiry.
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

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