AACV Walk for Autism 2021 Registration Form
Note: This form serves as a registration and release waiver for ALL people listed. Please ONLY include members of the SAME HOUSEHOLD.
Email *
Full NAME of Household Member #1
Household Member #2 (if applicable)
Household Member #3 (if applicable)
Household Member #4 (if applicable)
Household Member #5 (if applicable)
Household Member #6 (if applicable)
TEAM name (indicate if walking as an individual) *
Have you walked with us before? *
Phone Number (We promise not to bug you unless it's REALLY important.) *
Would you like to receive emails about other AACV events? *
Activity Release Form For and in consideration of permitting ______________________________ (the “Participant”) to take part in the Autism Alliance of the Concho Valley, Walk for Autism (the “Walk”) on the site of the Riverstage, City of San Angelo, I hereby expressly and knowingly RELEASE THE CITY OF SAN ANGELO AND/OR POSSIBILITIES OF THE CONCHO VALLEY, ITS OFFICERS, AGENTS, VOLUNTEERS, AND EMPLOYEES FROM ANY AND ALL CLAIMS AND CAUSES OF ACTION I MAY HAVE FOR PROPERTY DAMAGE, PERSONAL INJURY OR DEATH SUSTAINED BY ME ARISING OUT OF MY PARTICIPATION IN THE WALK, WHETHER CAUSED BY MY OWN NEGLIGENCE OR THE NEGLIGENCE OF THE CITY OF SAN ANGELO AND/OR POSSIBILITIES OF THE CONCHO VALLEY, ITS OFFICERS, AGENTS, VOLUNTEERS, OR EMPLOYEES.I hereby give my consent for any medical treatment that may be required during my participation with the understanding that the cost of any such treatment will be my responsibility. Further, I voluntarily and knowingly agree to HOLD HARMLESS, PROTECT, AND INDEMNIFY the City of San Angelo and/or Possibilities of the Conch Valley, its officers, agents, volunteers, and employees, against and from any and all claims, demands, or causes of action for property damage, personal injury or death, including defense costs and attorney’s fees, arising out of my participation in the Walk, REGARDLESS OF WHETHER SUCH DAMAGES, INJURY OR DEATH ARE CAUSED BY MY OWN NEGLIGENCE, OR BY THE NEGLIGENCE OF THE CITY OF SAN ANGELO AND/OR POSSIBILITIES OF THE CONCHO VALLEY, ITS OFFICERS, AGENTS, VOLUNTEERS, OR EMPLOYEES. The City of San Angelo and/or Possibilities of the Concho Valley shall notify me promptly in writing of any claim or action brought against it in connection with my participation in these activities. Upon such notification, I, or my representative, shall promptly take over and defend any such claim or action. COVID 19 Information: We ask the following individuals to refrain from attending the AACV Walk for Autism. 1. Individuals who currently or within the past fourteen (14) days have experienced any symptoms associated with COVID-19, which include fever, cough, and shortness of breath among others; and/or 2. Individuals who have traveled at any point in the past fourteen (14) days either internationally or to a community in the U.S. that has experienced or is experiencing sustained community spread of COVID-19; and/or 3. Individuals who believe that they may have been exposed to a confirmed or suspected case of COVID-19 or have been diagnosed with COVID-19 and are not yet cleared as non-contagious by state or local public health authorities or the health care team responsible for their treatment. DUTY TO SELF-MONITOR: Participants and volunteers agree to self-monitor for signs and symptoms of COVID-19 (symptoms typically include fever, cough, and shortness of breath) and, contact AACV at possibilitescv@gmail.com if he/she experiences symptoms of COVID-19 within 14 days after participating or volunteering with AACV. ASSUMPTION OF THE RISK. I acknowledge and understand the following: 1. Participation includes possible exposure to and illness from infectious diseases including but not limited to COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; 2. I knowingly and freely assume all such risks related to illness and infectious diseases, such as COVID-19, even if arising from the negligence or fault of the Released Parties I HAVE READ AND UNDERSTOOD THIS DOCUMENT, AND MY AGREEMENT AND DIGITAL SIGNATURE EVIDENCES MY INTENT TO BE BOUND BY ITS TERMS. *
Digital Signature (type your full name to indicate agreement to waiver detailed above) *
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