COMPANY NAME
CLASS/EVENT NAME Liability Waiver
PARTICIPANT’S NAME: ___________________________________________________________
BIRTH DATE: ___________________
HOME ADDRESS: ________________________________________________________________
HOME TELEPHONE: _________________________ CELL PHONE: _________________________
E-MAIL: _______________________________________________________________________
- A) EMERGENCY CONTACT NAME AND TELEPHONE NUMBERS:
NAME: ________________________________________ RELATIONSHIP: __________________
HOME PHONE: _________________________ CELL PHONE: _________________________
- B) IF “A” UNAVAILABLE, ALTERNATE EMERGENCY CONTACT NAME AND TELEPHONE NUMBERS:
NAME: ________________________________________ RELATIONSHIP: __________________
HOME PHONE: _________________________ CELL PHONE: _________________________
Nature of the Business: By signing this waiver, you agree that you may be giving up legal rights and remedies available to yourself. Read and complete this waiver carefully. If you have questions, contact an attorney.
I understand that the nature of the CLASS/EVENT is both social and spiritual in nature and are open to anyone.
Nature of Risks: I understand that voluntarily traveling to and attending the various CLASS/EVENT may involve certain risks beyond the reasonable control of its staff, director, volunteers, and agents in connection with the various CLASS/EVENT, including but not limited to accidents, emergencies, exposure to reckless conduct of other persons and/or negligence of, and that COMPANY NAME, et al., disclaim any and all responsibility for any such risks.
Waiver of Liability/Hold Harmless: By signing this liability waiver, I agree and acknowledge that I may be giving up important legal rights and remedies available to myself. For value received, I agree on behalf of myself that I assume all risks and waive any liability of any nature whatsoever against and agree to hold harmless COMPANY NAME, OWNER/TEAM MEMBERS with respect to any and all actions, claims or demands that may be made or brought on our behalf against COMPANY NAME, OWNER/TEAM MEMBERS arising out of or in connection with travel to or attendance at the CLASS/EVENT, or any other activity I may engage in while in transport there. Further, for value received, for any injury to third parties that may arise because of my actions or omissions, I agree to hold harmless and defend COMPANY NAME, OWNER/TEAM MEMBERS with respect to any and all actions, claims, expenses or demands arising there that may be made or brought against COMPANY NAME, OWNER/TEAM MEMBERS, including but not limited to reasonable attorneys’ fees and expenses arising in connection therewith.
Media Waiver: We consent to the use by COMPANY NAME, OWNER/TEAM MEMBERS any videotape, photograph, slide, audiotape, or any other visual or audio reproduction in which I may appear. I understand that these materials are being used for promotion of various CLASS/EVENT by and for OWNER. Such promotional activities extend to recruitment, fund-raising, advocacy, etc. I release COMPANY NAME, OWNER/TEAM MEMBERS from any liability connected with the use of my picture or voice recording as part of any of the above or similar activities.
Medical Permissions (Limited): As a condition attending the various events, I grant permission in the event of an emergency or accident, for emergency medical care to be administered within the Facility and/or during or after transportation to a hospital or doctor for emergency medical care. I further understand that it is not the responsibility of COMPANY NAME, OWNER/TEAM MEMBERS to attempt to reach my emergency contacts and that I remain responsible for my medical expenses.
Insurance Information
Policy in the name of: ____________________________________________________________
Insurance Company Name/Policy Number: ___________________________________________
I fully understand the consequences of and sign this LIABILITY WAIVER AND PERMISSION knowingly, freely, and willingly.
____________________________________________________ _____________________
Signature of Participant Date
