Waiver, Indemnification, And Medical Treatment Authorization Form printable pdf download

PARTICIPANT NAME

WAIVER, INDEMNIFICATION, AND MEDICAL TREATMENT AUTHORIZATION FORM

1. EXCULPATORY CLAUSE. In consideration for receiving permission for _________________________’s participation in any and all activities of District 8

4-H County Camp (herein referred to as “camp”), which is sponsored by District 8 Texas 4-H & Youth Development, (herein referred to as “sponsor”), I

hereby release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes sponsor, The Texas A&M University System, the

Board of Regents for The Texas A&M University System, Texas AgriLife Extension Service, Texas 4-H and Youth Development Program, Texas 4-H Youth

Development Foundation, Texas A&M University, Lakeview Methodist Conference Center, and their members, officers, servants, agents, volunteers, or

employees (herein referred to as RELEASEES or INDEMNITEES) from any and all liabilities, claims, demands, injuries (including death), or damages, including

court costs and attorney’s fees and expenses, that may be sustained by me/my child while participating in such activity, while traveling to and from the

activity, or while on the premises owned or leased by RELEASEES, including injuries sustained as a result of the sole, joint, or concurrent negligence,

negligence per se, statutory fault, or strict liability of RELEASEES. I understand this waiver does not apply to injuries caused by intentional or grossly

negligent conduct.

2. INDEMNITY CLAUSE. I am fully aware that there are inherent risks to my child, myself and others involved with this activity, including but not limited to:

(1) The tendency of an animal to behave in ways that may result in injury, harm or even death to persons on or around them; (2) The unpredictability of an

animal’s reaction to such things as sounds, sudden movement and unfamiliar objects, persons or other animals; (3) Certain hazards such as surface and

subsurface conditions; and (4) Collisions and contact with other animals or objects. I choose to voluntarily participate/allow my child to participate in said

activity with full knowledge that the activity may be hazardous to me, my child and my property, and to the person and property of others. I acknowledge

there may be physically strenuous activities. I know of no medical reason why I/my child should not participate. I agree to indemnify and hold harmless

INDEMNITEES from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses,

which may occur to myself, my child, other participants, and third-persons as a result of my/my child’s participation in said activity, including injuries

sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of INDEMNITEES.

3. NO INSURANCE. I understand that RELEASEES may or may not maintain any insurance policy covering any circumstance arising from my/my child’s

participation in this activity or any event related to that participation. As such, I am aware that I should review my personal insurance coverage.

Organization may not carry general liability insurance to cover claims arising from this activity so it seeks a waiver of claims as additional consideration for

the right to participate so organization, can (a) provide the activity at the lowest possible cost to participants; and (b) provide access to a greater number of

participants by expending limited resources on program materials rather than on liability insurance.

4. BINDS HEIRS. It is my express intent that this agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and

personal representatives, if I am deceased, and shall be governed by the laws of the State of Texas.

5. MEDICAL AUTHORIZATION, INDEMNITY FOR MEDICAL EXPENSES, and WAIVER. I understand RELEASEES cannot be expected to control all of the risks

articulated in this form and RELEASEES may need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any

medical treatment that may be required, as determined by a medical professional at the medical facility, during my/my child’s participation in this activity

with the understanding that the cost of any such treatment will be my responsibility. I agree to indemnify and hold harmless INDEMNITEES for any costs

incurred to treat me/my child, even if an INDEMNITEE has signed hospital documentation promising to pay for the treatment due to my inability to sign the

documentation. I further agree to release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes, RELEASEES from any

and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, that may be sustained by

me/my child while receiving medical care or in deciding to seek medical care, including while traveling to and from a medical care facility, including injuries

sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEES. I understand this

waiver does not apply to injuries caused by intentional or grossly negligent conduct.

6. VOLUNTARY SIGNATURE. In signing this agreement I acknowledge and represent that I have read it, understand it, and sign it voluntarily as my own free

act and deed; sponsor has not made and I have not relied on any oral representations, statements, or inducements apart from the terms contained in this

agreement. I execute this document for full, adequate and complete consideration fully intending to be bound by the same, now and in the future. I

understand I can choose not to sign this document and free myself and my child from its terms and the associated risks of the activity by simply not

participating in the activity and choosing some other activity available to me/my child that has a lower level of risk to myself and my child. I further

understand this is a voluntary, extracurricular activity. While I understand alternative activities are available to me/my child that do not have the risks

associated with this activity I still desire to voluntarily engage/permit my child to engage in this activity.

Participant Signature

Date

Participant Printed Name

Participant Date of Birth

Parent/Legal Guardian Signature

Date

Parent/Legal Guardian Printed Name

In case of emergency, contact:

Phone

If the participant has medical insurance, please indicate:

Insurance Company