HomeMy WebLinkAboutRelease of Claims Memo To Participants & Certification Form - 12-15-2016Harry Kim
Mayor
Charmaine L. Kamaka
Director
Ryan K. Chong
Deputy Director
County of Hawai`i
DEPARTMENT OF PARKS AND RECREATION
101 Pauahi Street, Suite 6 • Hilo, Hawai`i 96720
(808) 961-8311 • Fax (808) 961-8411
December 15, 2016
MEMORANDUM
To: All Persons/Groups Participating in P&R Programs or Using P&R Facilities
From: Charmaine L. Kamaka, Director
Re: RELEASE OF CLAIMS REQUIREMENT
The County of Hawai'i Department of Parks & Recreation ("P&R") is committed to providing
facilities for recreational and leisure activities at little or no cost to the people of the Island of
Hawai'i and its visitors. In order to do this we need to take proactive steps to reduce the
County's potential liability when persons voluntarily participate in P&R activities or use P&R
facilities. Therefore, as part of its risk management, P&R must require every participant to sign
a Release of Claims form prior to participating in any P&R program or using a P&R facility. A
participant under the age of eighteen must have a parent or guardian's signature.
The head of every group or organization, or a designee, must please do the following:
1. Fill out the activity information on the attached Release of Claims form;
2. Copy and distribute one form to each participant;
3. Collect the completed, signed form from each participant;
4. Proofread each form for completeness and signature (all signatures must be witnessed
by an adult.)
5. Return any incomplete form to the participant, to be completed & resubmitted;
6. Keep a copy of each participant's form with you at all times (a P&R employee may ask to
see your group's forms at any time the group is using a county facility or program);
7. Submit all original forms to the assigned P&R employee before the start date of the
activity/program written on the form. Failure to sign a form, or late submission of forms,
may result in the individual or group being unable to participate in the County program or
use the County facility.
8. Sign and submit the attached certification form.
Please contact the P&R recreation director or employee at (phone) _____________ if you
have any questions or concerns regarding this requirement.
Thank you in advance for your anticipated cooperation, as we work together to provide a
responsible and positive recreational experience for everyone.
County of Hawai`i is an Equal Opportunity Provider and Employer.
CERTIFICATION OF PERSON SUBMITTING
RELEASE OF CLAIMS FORMS FOR
__________________________________
(Fill in name of group or organization)
I, ___________________________________________________________, am the
(Print full legal name)
____________________________ of the ______________________________________
(Title or position) (Name of group/organization)
and hereby certify that:
1. I have distributed a Release of Claims form to each participant;
2. I have explained to each participant that:
a. a completed, signed form must be submitted to P&R prior to any person (adult or minor)
participating in a P&R program or using a P&R facility;
b. any participant who has not submitted a signed Release of Claims form may not participate
in the P&R program and/or use the P&R facility;
3. I have reviewed each participants form for accuracy and completeness;
4. I have COPIES of all signed waiver forms and will have them with me or another group member at
all times that our group is using a P&R program or facility;
5. I am submitting all ORIGINAL waiver forms to P&R prior to the start date indicated on the waiver
form (unless prior written permission has been obtained from the County, a copy of which is
attached to this certification);
6. I understand I am responsible to notify all latecomers of this requirement, and to submit a signed
Release of Claims form prior to any latecomers participation; and
7. I will not allow any individual in my group/organization to participate if a Release of Claims form
has not been signed and submitted to the County prior to any individuals participation or use of a
County program or facility.
_______________________________ ____________________________________
Signature Witness Signature (Age 18 or older)
_______________________________ ____________________________________
Date Printed Name
_______________________________ ____________________________________
Address Address
_______________________________ ____________________________________
Day Phone Number Phone Number
Release of Claim - Certification Form - 5-23-06