Dpr Accident Waiver And Release Of Liability Form

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DPR
DC DEPARTMENT OF PARKS AND RECREATION
DISTRICT   O F   C OLUMBIA   D EPARTMENT   O F   P ARKS   A ND   R ECREATION   ( “DPR”)  
ACCIDENT   W AIVER   A ND   R ELEASE   O F   L IABILITY   F ORM  
 
Name   o f   A ctivity,   E vent,   o r   P rogram   ( hereinafter,   t he   “ Activity”):______________________________________  
 
Date(s)   o f   A ctivity:____________________________________________________________________________  
 
Location   o f   A ctivity:___________________________________________________________________________  
 
I  HEREBY  ASSUME  ALL  OF  THE  RISKS  OF  PARTICIPATING  IN  THIS  ACTIVITY,  including,  but  not  limited  to,  any  
risks  that  may  arise  from  the  condition  of  the  equipment  and/or  real  and  personal  property  owned,  managed,  
maintained,   a nd/or   c ontrolled   b y   t he   D istrict   a t   t he   l ocation   o f   t he   A ctivity.  
 
I   r ecognize   t hat   p articipation   i n   t he   A ctivity   c an   c arry   w ith   i t   p otential   r isks,   i ncluding,   b ut   n ot   l imited   t o,   b odily  
injury.     I   certify   that   I   have   not   been   advised   to   refrain   from   participating   in   the   Activity   by   a   medical  
professional.     T here   a re   n o   h ealth-­‐related   r easons   o r   p roblems   t hat   p reclude   m y   p articipation   i n   t his   A ctivity.      
 
I  hereby  consent  to  receive  medical  treatment  that  may  be  deemed  advisable  in  the  event  of  injury,  accident  
and/or  illness  during  this  Activity.    However,  this  consent  does  not  require  DPR  to  initiate  medical  care  on  my  
behalf.    I  agree  to  accept  full  responsibility  for  and  to  pay  for  the  cost  of  medical  care,  transportation  and  any  
other   i ncidental   e xpenses   a rising   f rom   a ny   s uch   e vent.  
 
In   consideration   of   receiving   permission   to   participate   in   this   Activity,   I   hereby   take   action   for   myself,   my  
executors,   a dministrators,   h eirs,   n ext   o f   k in,   s uccessors   a nd   a ssigns   a s   f ollows:    
 
(A)   I   WAIVE,   RELEASE   AND   DISCHARGE   the   District   of   Columbia   and   its   agencies,   agents,   employees,  
volunteers,  contractors,  sponsors,  advertisers,  partners,  and/or  representatives  (each  a  “District  Party”  
and   collectively   the   “District   Parties”)   from   any   and   all   liabilities,   claims,   penalties,   suits,   demands,  
judgments,   costs,   interest,   and   expenses   (including,   attorneys’   fees   and   costs)   (each   a   “Loss”   and  
collectively  the  “Losses”)  including,  but  not  limited  to,  Losses  arising  from  or  connected  in  any  way  to  
my  death,  disability,  personal  injury,  property  damage,  property  theft  or  actions  of  any  kind  which  may  
hereafter   o ccur   t o   m e   i n   c onnection   w ith   t he   A ctivity   i ncluding   m y   t raveling   t o   a nd   f rom   t his   A ctivity;    
 
(B)  I  AGREE  TO  INDEMNIFY  and  HOLD  HARMLESS  the  District  Parties  for,  from,  and  against  any  and  all  
Losses   a rising   o r   r esulting   f rom   p articipation   i n   t his   A ctivity;    
 
I   c ertify   t hat   I   h ave   r ead   t his   d ocument,   t hat   I   a m   a t   l east   1 8   y ears   o ld   a nd   c an   s ign   t his   W aiver,   a nd   t hat   I   f ully  
understand  its  content.    I  am  aware  that  this  is  a  release  of  liability  and  is  a  contract  made  in  consideration  of  
my   p articipation   i n   t he   A ctivity.    
 
 
______________________________     _____________________________    
_________________    
Participant’s   N ame   ( Print)    
 
Participant’s   S ignature      
 
Date  
 
 
___________________________________________________________________________________________  
Participant’s   P hone   #   a nd   A ddress  
 
 
_______________________________________________  
Emergency   C ontact   N ame   a nd   P hone   #  
 
 

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