Montgomery Sycamore Island Club
Request and Release

I do represent and certify that I am the parent or legal guardian of the minor child (of less than 18 years age) named below and that I have the legal right to request and sign the liability release for this child.

I hereby request permission for my minor child to enter upon and use the premises and facilities of the Montgomery Sycamore Island Club (hereinafter referred to as "the Club") and to use a canoe, kayak, or other watercraft belonging to the Club or located on or launched from the Club premises. I have been advised of and am aware of the dangers of using such watercraft upon the Potomac River (specifically including the extreme danger of venturing near the Little Falls Dam). Knowing the risks and dangers necessarily involved in venturing upon the Potomac river in watercraft, and knowing that unexpected and unforeseen dangers may arise during such activity, I voluntarily assume all risks of death or injury to my child and my property that may be incurred in connection with or as a result of any activity this child will undertake while visiting the Club.

In consideration of the permission granted to my child to enter the Club premises and to use a canoe, kayak, or other watercraft belonging to the Club, or to launch such a watercraft from Club premises, I do hereby for myself, my heirs, administrators and assigns, release, remise and discharge the Club and its officers, directors, members, employees, and agents of, from all claims, demands, actions, and causes of action of any sort, for injuries sustained by my child or my property during their presence on the Club premises or during or as a result of their use of the Club, its facilities, or any Club watercraft or watercraft launched from the Club premises, whether due to negligence or any other fault.

Name of Child: __________________________________________ Age: _________

I have read and understand the foregoing request and release. In Witness Thereof, I have hereunto set my hand and seal:

Name of Parent or Legal Guardian: _________________________________________

Address: _____________________________________________________________

Tel (Work): ________________________   Tel (Home): ________________________

Signature: ______________________________    Date: ________________________