Waiver Form - Lakeland College (Page 3 of 3) in pdf

personal injury, death and property damage, that may arise from Lakeland’s own GROSS NEGLIGENCE, during the course of

planning, administering and running the Great Toboggan Ride, including:

a) any failure by Lakeland to supervise the Great Toboggan Ride and its participants, either properly or at all; and,

b) any failure to provide or make available suitable and adequate equipment or supplies fit for their purpose for the use of

participants in the Great Toboggan Ride; and,

c) any failure to ensure equipment and supplies, if any, provided for the use of participants in the Great Toboggan Ride are

adequately maintained, safe or adequate and fit for their purpose; and,

d) any undertaking of, or failure to undertake, any course of action related to determining or maintaining the safety of the

geographical course and condition of the Great Toboggan Ride; and,

e) any undertaking of, or failure to undertake, any course of action related to the safety of any participant in the Great Toboggan

Ride;

and I shall be solely and exclusively responsible for any costs, liabilities, damages or injury or death or property damage that I may

suffer or that I may cause to other persons or individuals or to property as a consequence of any such GROSS NEGLIGENCE by

Lakeland, to the total and absolute exclusion and exoneration of any liability by Lakeland for any such GROSS NEGLIGENCE.

This Gross Negligence Release is binding on me and my heirs, next of kin, executors, administrators and personal representatives.

In granting this Release, Waiver and Indemnity and the Gross Negligence Release included in this document I am not relying on any

oral or written representations or statements made by Lakeland other than as set forth in this document, and this is the entire

agreement and there are no other or collateral or “side-agreements” made in addition to what is stated herein. This document is

signed and delivered unconditionally.

I have read and understand this agreement and I am aware that by signing this agreement I am waiving certain legal rights

which I may have, or my heirs, next of kin, executors, personal representatives and administrators may have against

Lakeland, and to confirm that I have read this document i have printed in the word “y e s” in the following space ________

Signed this _______ day of ________________, 2013.

WITNESS TO SIGNATURES

APPLICANT

__________________________________

Signature of Witness

Signature of Applicant

__________________________________

Witness Name (Please print clearly)

Applicant Name (Please print clearly)

Please list any medical or other conditions which may affect your participation and which Lakeland should be aware of, including

epilepsy, heart condition, asthma, etc.:

_______________________________________________________________________________________________________

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Waiver Form - Lakeland College Page 3