Buffalo Grove, ILBuffalo Grove

PARENT AND EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACT (if above are unavailable):

Village of Buffalo Grove Participant Liability Waiver and Hold Harmless Agreement Please read this form carefully and be aware that by registering for and participating in this program, you will be waiving your rights to all claims for injuries you might sustain arising out of this program and you will be required to indemnify, hold harmless and defend the Village of Buffalo Grove for any claims arising out of participation in the Buffalo Grove Junior Police Academy Program. Risk of Injury: “As a participant in the program, I recognize and acknowledge that there are certain risks of physical injury, including but not limited to adverse and stressful situations accompanying law enforcement activities: heart attacks, strokes, heat stress, sprains, broken bones and torn muscles or ligaments and I agree to assume the full risk of injuries, including death, damages, or loss which I may sustain as a result of participating in any and all activities associated with this program.” Waiver of Injury Claim:“I agree to waive and relinquish any and all claims I may have arising out of, connected with, or in any way associated with the activities of the program." Release from Liability: “I do hereby fully release and discharge the Village of Buffalo Grove and its officers, agents and employees from any and all claims from injuries, including death, damage or loss which I may have or which may occur on account of participation in this program. Indemnity and Defense: “I further agree to indemnify, hold harmless and defend the Village of Buffalo Grove and its officers, agents and employees from any and all claims from injuries, including death, damages and loss sustained by me arising out of, connected with or in any way associated with the activities of the program.” Criminal History Check:“I do hereby grant permission for a law enforcement records check to be performed. The undersigned waives all right of privacy regarding criminal history information, understanding that all Junior Police Academy records are confidential. I understand that should it be determined that I have a criminal arrest record I willnot be allowed to participate in the Junior Police Academy.” *As a way of promoting the Junior Police Academy, photographs and video imagery will be taken during the academy sessions which might be used on the Village of Buffalo Grove's website, social media accounts, or in a local newspaper.

I have read and fully understand and agree to the above state conditions of participation in the Buffalo Grove Police Department's Junior Police Academy.

I have read and fully understand and agree to the above stated conditions of participations in the Buffalo Grove Police Department's Junior Police Academy and give permission for my child, the listed applicant, to attend.