Accident Waiver And Release Of Liability (Page 2 of 2) in pdf

Accident Waiver And Release Of Liability Page 2

death. I hereby consent to receive medical treatment which may be deemed advisable in

the event of injury, accident and/or illness during this event. In the event of accident

and/or injury I further consent to the release of any and all transport, treatment and or

medical information to the Association relating thereto. I understand that at these

Activities or related events, I may be photographed. I agree to allow my photo, video,

film likeness and email address to be used for any legitimate purpose by the event

holders, producers, sponsors, organizers and or assigns. I agree to participate in the

Activities in accordance with all applicable laws. This Waiver and Release shall be

construed broadly to provide a release and waiver to the maximum extent permissible

under applicable law.

ACKNOWLEDGEMENT OF RISK AND RELEASE

Name (first, last): _______________________________________________________

Mailing Address: _______________________________________________________

City: ___________________ State: _____________ ZIP:_________

Phone: ________________________________________

Secondary Phone (optional): ___________________________

Email Address (REQUIRED):

_______________________________________________

Emergency Contact (REQUIRED – name, relationship, and phone):

_________________

_______________________________________________________

I, the undersigned, agree for myself and understand and agree to the following:

I have read, acknowledge, and understand the Waiver and Release set forth above.

This acknowledgement of risk and release shall not be modified orally.

Name (printed): __________________________________________________________

Signature: _______________________________________________________________

Date: _______________________________________________________

909027-1

Accident Waiver And Release Of Liability Page 2