Special Event Checklist (Page 6 of 8) in pdf

Special Event Checklist Page 6

Revised January 22, 2015

Addendum #4 (Submit if applicable)

OMEGA PSI PHI FRATERNITY, INC.

ATHLETIC EVENT PARTICIPATION WAIVER

__________________________________________________________________________________

I, ____________________________________ a registered participant in an activity

sponsored by _______________Chapter of Omega Psi Phi Fraternity, Inc., understand and

agree that I am participating in this event on my own free will and accord and that neither

_________________ Chapter, nor Omega Psi Phi Fraternity, Inc., nor its insurer(s) will share

in or accept responsibility for any liability for bodily injury, property damage, medical expense

or other loss that may arise from my participation in this event.

I further understand and agree, and have no expectation that _________________ Chapter,

or Omega Psi Phi Fraternity, Inc. will provide any form of security or other measure of

safeguarding for this event, as there is no reasonable expectation that such will be necessary.

I further understand and agree that this event is considered a “no-fault” event by me, as well

as ___________________ Chapter, and Omega Psi Phi Fraternity, Inc. and in the event of

bodily injury, property damage, necessity of medical expenses or other loss, I agree to incur

my own expenses without input or participation from

_________________ Chapter, or Omega Psi Phi Fraternity, Inc., or its insurer(s).

_________________________

Guest/Participant

Chapter Representative

_________________________

Witness

______________________________

_______________________________

Date

This form should be only used for athletic events and completed for all participants.

Chapters should keep the waiver forms for possible liability issues and record keeping

purposes.

* Required Signatures – Checklist will be returned and not processed if all required signatures are not listed.

Special Event Checklist Page 6