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2. Must be 18 years of age or older

4. Name:*
5. Address*
7. Phone:*
8. Email:
10. Name of Current City Gym Member Accompanying You:*
12. Are you a sex offender as defined in IC 11-8-8-5 and required to register with the local law enforcement authority under IC 11-8-8?*

    1. No
    2. Yes

16. RULES

    1.  No alcoholic beverages, illegal drugs or smoking in the gym or other gym associated facilities.

    2. Turn out all lights when you finish using any gym facility and secure doors as you leave.

    3. All facilities are to be used at your own risk.

    4. Gym hours are 5 am to 11 pm—no activities past 11 pm without prior approval by the Park Board.

    5. 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 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.

20. I, the undersigned, on behalf of myself, any family member listed below, executors, administrators, heirs, next of kin, successors and assigns, HEREBY WAIVE, RELEASE AND DISCHARGE, the City of Bluffton, the Bluffton Parks & Recreation Department, 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 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, as indicated above, which arise out of my/our using the facilities owned by the City of Bluffton or any department thereof. The undersigned understands that by signing this agreement, they are relieving the City of Bluffton from any obligation to pay for any damages or injuries that occur while any member of the undersigned’s family is engaged in activities connected with the Bluffton City Gym.

    I HEREBY AFFIRM that I am eighteen (18) years of age or older, that I have read this form in its entirety & understand its contents, and that I agree to abide by all the rules outlined in this membership form. Any violations of these rules may result in immediate revocation of my privileges.

22. Date:*
    Date:
23. Digital Signature*
25. 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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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field