Activity Permission Slip
ACKNOWLEDGEMENT OF RISKS AND RELEASE OF LIABILITY
Release of Liability - Informed Consent Form (For a Minor)
You must read and agree to the terms of the Waiver in order for your child(ren) to participate in the program.
In consideration of being allowed to participate in any way in the Vehicle for Change Adventure Program, related events and activities (hereafter called the Program), I the undersigned, acknowledge, appreciate, and agree that:
- The risk of injury from the activities involved in this program is significant during all phases of the activity, including the potential for permanent paralysis, disability and death. These risks include but are not limited to: Equipment failure and/or malfunction of my own or other’s equipment; my own negligence and/or the negligence of others; slips, falls and contact with the wall or challenge elements. Attack or encounter with insects, reptiles and/or animals; Fatigue, chill and/or dizziness which may diminish my/our reaction time and increase the risk of accident; Outdoor activities include but are not limited to risks of exposure to elements, excessive heat, hypothermia, exposure to animals with the risk of them kicking, biting, or moving in an unanticipated manner causing injury and/or death. I agree to wear any necessary safety equipment provided to me and use as instructed. I recognize that failure to do so will increase the potential for severe injury or death and absolves the RELEASEES from any liability whatsoever.
- I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation in the Program.
- I willingly agree to comply with terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.
- I recognize that it may be necessary for the (Releasees) to refuse or terminate my participation if I am judged to be incapable of meeting the rigors or requirements of the Program. I accept the (Releasees) right to take such actions for the safety of myself, my child and/or other participants. I will not engage in any activity beyond my capabilities and will not cause any third party to be endangered by any of my actions during the program. I warrant and represent that I and my child are in good health and have no physical or mental limitations or problems that would affect my/our safe participation or the safety of others in the program and have not been advised otherwise by a qualified medical person.
- By participating in or attending any activity in connection with this program, whether on or off the premises, I / my child consents to the use of any photographs, pictures, film or videotape taken of me or provided by me for publicity, promotion, television, websites or any other use, and expressly waive any right of privacy, compensation, copyright or other ownership right connected to same.
- I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE VEHICLE FOR CHANGE , its officers, officials, agents and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the program (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
- I agree that any film or photographs of me/us, as participants, become your property and may be used for promotional or commercial purposes.
By submitting the form (clicking on submit) I understand the foregoing acknowledgment of risk, assumption of risk and responsibility and release of liability.
If you have any questions, please call 1.877.841.1110.