Va Form 0926d - Waiver & Release Of Liability And Other Use Release - 2012
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1OMB Number: 2900-0759
Respondent Burden: 20 minutes
WAIVER & RELEASE OF LIABILITY
AND OTHER USE RELEASE
2012 NATIONAL VETERANS GOLDEN AGE GAMES
PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17,
Section 1710. VA may disclose the information that you put on this form as permitted by law. VA may make a "routine use"
disclosure of the information as outlined in the Privacy Act systems of records notices identified as 121VA19 “National Patient
Databases - VA”. Providing the requested information is voluntary.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor,
and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who must complete this application will average 20 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the forms.
In consideration of being allowed to participate in the 2012 National Veterans Golden Age Games, related events, and
activities, (collectively the "Games"), I , the undersigned, acknowledge, appreciate, and agree that:
1. The risk of injury from the activities involved in these Games is significant, including the potential for serious
bodily injury, including death, and property damage. I am fully aware of the risks and hazards associated with
participating in these Games and I voluntarily, without any inducement, elect to participate in the Games. I
KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN
IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERS, and assume full responsibility for
my participation.
2. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I
observe any unusual, significant hazard during my presence or participation, I will remove myself from participating
and bring such to the attention of the nearest official immediately.
3. I, for myself and on behalf of my heirs, assigns, personal representatives, administrators, and next of kin,
HEREBY RELEASE, HOLD HARMLESS, COVENANT NOT TO SUE, AND FOREVER DISCHARGE the
United States Government; the Department of Veterans Affairs ("VA"); VCS; HHV; their officers, directors,
members, vendors, contractors, agents, and employees; and, any and all sponsoring agencies, sponsors, advertisers,
owners, and lessors of premises used to conduct the Games, related events and activities; and officials, volunteers,
and other participants of the 26th National Veterans Golden Age Games, from any and all liability, claims, demands,
actions, and causes of action whatsoever arising out of or related to any and all injury, disability, death, or loss or
damage to person or property, whether arising from the negligence of any of the RELEASEES, or otherwise, while
participating in the Games.
4. I consent to medical treatment in the case of emergency. I agree to assume full responsibility for payment of any
and all fees incurred as a result of such medical treatment.
I HAVE READ THIS ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS,
UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY
AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
SIGNATURE (MANDATORY)
DATE SIGNED
NAME PLEASE PRINT (First, MI, Last)
ADDRESS (Street, City, State and Zip Code)
IN CASE OF EMERGENCY, NOTIFY:
NAME
TELEPHONE NUMBER
RELATIONSHIP
0926d
VA FORM
OCT 2011
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