RIVER SIRENS, INC.
INSTRUCTIONS: COMPLETE THIS FORM FULLY AND SIGN RELEASE AND
WAIVER OF LIABILITY AT THE BOTTOM.
PLEASE RETURN THIS FORM AND ANY APPLICABLE PAYMENT IN FULL TO ANY
OFFICER/DIRECTOR/COACH IN PERSON OR BY MAIL TO:
RIVER SIRENS, INC., c/o 706 Avondale Avenue,
Haddonfield, New Jersey 08033 USA,
Attn: Membership
IN CONSIDERATION of being given the
opportunity to be a member of the River Sirens, Inc., (RSI), I
____________________________
my
personal representatives, assigns, heirs, and next of kin:
(PRINT NAME)
1.
ACKNOWLEDGE, AGREE, AND REPRESENT that I understand that the primary nature of
the activities in which members of RSI are engaged, including paddling both on
water and on land (individually an “Activity” and collectively, the
“Activities”), require strenuous physical exercise and that I am qualified, in
good health, and in proper physical condition to participate in such
Activities. I will notify the
appropriate coach, supervisor, officer, director or agent if I have, or if I
develop, any physical problems or health conditions that may affect my ability
to participate in the Activities without posing a danger to my health or safety
or the health or safety of others.
2.
FULLY UNDERSTAND that (a) the Activities involve risks and dangers of serious bodily
injury, including permanent disability, paralysis, and death (“Risks”); (b)
these Risks may be caused by my own actions or inactions, the actions or
inactions of others participating in the Activities, the condition in which the
Activities takes place, or the negligence of the Releases named below; (c)
there may be other risks and social and economic losses either not known to me
or not readily foreseeable at this time.
I FULLY ACCEPT AND ASSUME ALL RESPONSIBILITY for losses, costs, and
damages I incur as a result of my participation in the Activities.
3.
AGREE AND WARRANT that I will examine each
Activity in which I participate and that if I observe any condition to be
unreasonably risky or dangerous, I will notify the proper authority and not
take part in the Activity until the condition has been corrected to my
satisfaction.
4.
HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE RSI, its administrators,
officers, directors, agents, coaches, volunteers, other participants, sponsors,
advertisers, and if applicable, owners and leasers of premises on which the Activity
takes place (all of which are hereinafter referred to as “Releasees”)
from any and all liability to undersigned, his or her heirs and next of kin,
for any and all claims, demands, losses or damages on my account, caused or
alleged to be caused, in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue
operations. I further agree that if,
despite this Release and Waiver of Liability, Assumption of Risk, and Indemnity
Agreement, I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS each
of the Releasees from any litigation expenses,
attorney fees, loss, liability, damage, or cost which may incur as a result of
such claim.
I
HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE
GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGNED IT FREELY AND WITHOUT ANY
INDUCEMENT OR ASSURANCE OF ANY NATURE. I intend it
to be a complete and unconditional release of all liability to the greatest extent
allowed by law and I agree that if any portion of this agreement is determined
to be invalid, all other parts shall continue in full force and effect.
PERSONAL
INFORMATION:
Address:
_______________________________________________________________________________________________________
Telephone: ___________________ Check One ( ) Home ( ) Work ( ) Mobile…E-Mail Address: __________________________
Date of Birth: _______________ Height: __________ Weight: __________ Paddle Side (if known): Left ( ) Right ( ) Both ( )
Emergency Contact Name: ______________________ Relation: _________________ Emergency Telephone: _________________
Health Information: Do you have any physical or medical condition(s) that may affect your ability to paddle safely?
If yes, please explain: ____________________________________________________________________________________________
________________________________________________________________________________________________________________
_____________________________________________ ________________________________________________________________
Print Name of Participant Print Name of Parent/Guardian (where Participant is under the age of 18)
__________________________________________________________________________ Date: ______/______/______
Signature of Participant or Parent/Guardian (where Participant is under the age of 18)
Last updated 11/16/2006