Release And Waiver Of Liability, Assumption Of The Risk And Indemnity Agreement And Consent To Medical Treatment Template

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RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF THE RISK AND
INDEMNITY AGREEMENT AND CONSENT TO MEDICAL TREATMENT
By our signatures below, we acknowledge that we are aware of, appreciate the character
of, and voluntarily assume the risks involved in participating in
________________________________________________________________________
________________________________________________________________________
By our signatures below, on behalf of ourselves, our heirs, next of kin, successors in
interest, assigns, personal representatives, and agents, we hereby:
1. Waive any claim or cause of action against and release from liability the State
of South Dakota, its officers, employees, and agents for any liability for injuries to
person or property resulting from participation in the activity listed above;
2. Agree to indemnify and hold harmless the State of South Dakota, its officers,
employees, and agents for any claims, causes of action, or liability to any other person
arising from participation in the activity listed above;
3. Consent to receive any medical treatment deemed advisable during
participation in the activity listed above; and
4. Acknowledge that we are signing below as a minor child and as the parent or
legal guardian of the minor child named below.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF
THE RISK AND INDEMNITY AGREEMENT AND CONSENT TO MEDICAL
TREATMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE
GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT
FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE,
OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A
COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE
GREATEST EXTENT ALLOWED BY LAW.
Minor’s Name ________________________________ Date of Birth ______________
Signature ______________________________ Address________________________
Date______________________________________
Guardian’s Name___________________________ Date of Birth__________________
Signature _________________________________ Address ______________________
Date______________________________________
EXHIBIT G
9-7
07/2003

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