Form Tcdg - Waiver Of Liability And Hold Harmless Agreement Form (Page 3 of 3) in pdf

Form Tcdg - Waiver Of Liability And Hold Harmless Agreement Form Page 3

2014

UMMER

NSTITUTE

PLEASE READ ALL SECTIONS OF THIS DOCUMENT CAREFULLY

ACTIVITIES OFFERED AND POSSIBLE INJURIES, WHICH MAY OCCUR

There are risks involved when participating in the following activities offered. Some of the possible injuries and bodily harm,

which can occur through participation in the activities, are listed below. This list is provided to make the prospective participant

aware of the possibilities of injuries, which may be sustained. The individual is completely responsible for his/her own safety and

health.

Flag football Volleyball

Soccer Bicycling

Tennis Swimming

Basketball Track and Field

Racquetball Weight Lifting

Softball Various special events

POSSIBLE INJURIES:

Strains, sprains, pulls, tears, cramps, infection, rashes, bruises, contusions, wounds (such as abrasions, incisions, lacerations,

punctures), insect bites, dislocation, blisters, nosebleeds, broken bones, fractures, choking, respiratory or heart failure,

exhaustion, heat stroke, fainting, nerve damage, shock, paralysis, concussion, and in extreme case—death.

BODY AREAS, WHICH MAY BE AFFECTED OR INVOLVED IN SPORTS INURIES:

Head, face, eye, ear, jaw, teeth, mouth, neck, nose, chest, abdomen, back, arms, elbow, hands, fingers, wrist, shoulders,

genital organs, scalp, bones, leg, knee, hip, ankle, feet, toes, internal organs, nerves, muscles, cartilage, joints, tendons, spinal

cord, arteries, veins and brain.

I HAVE REVIEWED THE ABOVE INFORMATION AND AM AWARE OF THE RISKS INVOLVED IN PARTICIPATING

IN ACTIVITIES AND THE POSSIBLE INJURIES THAT MAY OCCUR. I FREELY AND VOLUNTARILY AGREE TO

PARTICIPATE IN ANY AND/OR ALL OF THE ACTIVITIES LISTED HERE WHICH ARE OFFERED IN THE PROGRAM.

_________________________________________________________________

PRINT Participant’s Name (required)

_________________________________________________________________ ______________________

Participant’s Signature (required)

Date

_________________________________________________________________

PRINT Parent’s or Legal Guardian’s Name (required)

_________________________________________________________________

________________________

Parent’s or Legal Guardian’s signature (required for participants under 18 years of age)

Date

TCDG Waiver of Liability and Hold Harmless Agreement 2014

Page 3 of 3

Form Tcdg - Waiver Of Liability And Hold Harmless Agreement Form Page 3