Family Fitness and Safety Challenge 5K and Event
Saturday, September 10, 2016
Release and Waiver
Before beginning any exercise program or event, you should consult with your physician. Exercise is an activity in which, despite careful and proper preparation, instruction, medical advice, and conditioning, there can still be a substantial risk of injury.
Please read this form carefully and be aware that by participating in this event you will be waiving your rights to all claims for any injuries you might sustain, and you will be required to indemnify, hold harmless and defend Jackson-Madison County General Hospital District ("Hospital") for any claims arising out of your participation in this event.
_________________________________________________
Acknowledgement of Status and Responsibility:
I acknowledge and agree that I am voluntarily participating in the event and that I am responsible for my own safety, health and welfare.
Risk of Injury
: I recognize and acknowledge that physical activity carries the risk of injury, and I agree to assume the full risk of injuries, including death, disability or
personal injury, property damage, property theft, or actions of any kind
which may hereafter occur to me including my traveling to and from the event location
, or loss which I may sustain as a result of my participation.
I understand that my participation is voluntary, and that I am choosing to accept the risks involved.
Waiver and Release of Liability
: In consideration of my participation, I agree on behalf of myself, my heirs and assigns, to waive, release and forever discharge the Hospital from any and all claims of negligence or other actions, whether foreseeable or unforeseeable, which may at any time arise out of or relate to my participation. This waiver and release of liability includes, but is not limited to, injuries which may occur as a result of slipping and falling while on the premises.
Indemnity
: I further agree to indemnify, hold harmless and defend the Hospital, its officers, agents, and employees from any and all claims related to injuries sustained by me and arising out of, connected with, or in any way associated with the activities or participation in the event.
Agreement Not to Sue:
I agree on behalf of myself, my heirs and assigns not to sue the Hospital for any reason related to my participation.
Emergency Treatment
. In the event of any e
mergency, I authorize the Hospital to secure any treatment deemed reasonable and necessary, and agree that I will be responsible for payment of any and all medical services rendered.
I have been given ample time to read this Acknowledgement and Release, and I have read and fully understand its contents. I understand that it is a release of liability and an acknowledgement of responsibility, and I sign this document knowing that I am waiving any right to bring a legal action against the Hospital for any claim relating to my participation in the event.
Print Participant's Name: __________________________________
Participant Signature: __________________________________
Date: __________________________________
For participants under 18 years of age:
I am the parent or guardian of ___________
______________________________________ and hereby certify that he or she has my permission to participate in this event. I have read this release and intentionally and voluntarily accept its terms.
Guardian Signature:_________________________________Date:_______________________________
Consent and release for photography:
I, ________________________________, understand that this event may be photographed, filmed, or videotaped and I hereby grant to Jac
kson-Madison County General Hospital District, and persons acting for or through them, the right to use, reproduce, assign, and/or distribute my name and image in connection with this event for promotional, educational or any purposes.
Signature: _________________________________________Date: ________________
