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WAIVER AND RELEASE IN CONSIDERATION, of participating in any event occurring in connection with Blair County Respiratory Disease Society (BCRDS), and intending to be legally bound hereby, as well as binding my heirs and personal representatives, the undersigned acknowledges, agrees and irrevocably stipulates that: _______ Initial I will voluntarily be engaging in activities that may involve risk of serious injury, including scaring, permanent disability and death, and severe social and economic losses which might result not only from my own actions, inactions, or negligence but also of others, or the conditions of the premises or of any equipment used. Further that there may be others risks not known or reasonably foreseeable at this time. _______ Initial I hereby acknowledge, stipulate and agree that BCRDS is accepting my service in this event or activity, but reserves the right to revoke permission for my participation at any time for any reason if within the sole judgment of an BCRDS representative my participation is unsafe, inappropriate, or inconsistent with the BCRDS image. _______ Initial I am physically fit to be participating in the event and activity and I have consulted with my personal physician to obtain consent for my participation and for identification of any limitations, which I should abide by. _______ Initial The use of any equipment or facility, as well as work at any premises, is voluntary and at my own risk and liability and that no supervision, instruction, or monitoring will be provided. _______ Initial I hereby knowingly and freely represent and warrant that I am fully knowledgeable, familiar, experienced and trained by others on the use of any equipment that I am permitted to use. _______ Initial Prior to the use of any equipment or facilities, as well as work at any premises, and prior to participating in any event or activity, I have the responsibility to inspect the premises, facilities, and equipment and if anything is believed to be unsafe, I will immediately not work at the premises; not use the facility or equipment; and notify _______________of such condition. __________ Initial I assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death. _______ Initial I hereby release, waive, discharge and covenant not to sue BCRDS, its directors, agents, employees, administrators, its Landlords and its officers, stockholders, directors, employees and agents, their successors and assigns, other participants, sponsoring agencies, sponsoring advertisers, collectively the “Releasees” from any and all liability whatsoever, damages, losses claims, of any nature in any form, or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or part by the negligence of the Releasees or otherwise. THE UNDERSIGNED HAS READ THE ABOVE WAIVER AND RELEASE, AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT VOLUNTARILY. Date: ___________, 20 ___ (Signature) _________________________ Printed Name _________________________ |