Adult Waiver 2018
Every participant in Ecomaniacs program 18 years old or older must fill out this form prior to participation each year.
Participant's Full Name *
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Participant Date of Birth *
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Participant Email Address *
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Participant Phone Number *
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Volunteer Group/Organization Name *
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Emergency Contact Name
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Emergency Contact Phone Number
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VOLUNTEER RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, INDEMNITY AND CONSENT TO MEDICAL TREATMENT *
In consideration for being allowed to participate with the group identified below in the Ecomaniacs Program (“Program”) and engage in the activities related to the Program I hereby, on behalf of my heirs, next of kin, personal representatives and agents, certify, acknowledge and agree to the following: 1. Acknowledge that I am aware of and appreciate the character and risks of the Program and voluntarily assume the risks associated with participating in the Ecomaniacs Program. I understand that participation in the Program will involve physical activity exposure to the elements, and other circumstances which may result in personal injuries. I have also been provided the Ecomaniacs Handbook which sets out the guidelines and rules for participation and acknowledge that I have reviewed and agree to follow them. 2. Waive any claim or cause of action against and release and discharge City of Sioux Falls and Ecomaniacs its officers, employees and agents and assigns from any liability or claim that the individuals listed above may have against Ecomaniacs and its successors with respect to any injuries to person or property, illness or death, that may result from participation in the Program, to the extent allowed by law including claims of negligence. 3. Understand and acknowledge that City of Sioux Falls and Ecomaniacs do not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness as a result of participation in the Program. 4. Agree to indemnify and forever hold harmless City of Sioux Falls and Ecomaniacs against any loss or expense, including reasonable attorneys fees, from any claims, demands or actions that may hereafter be made by any other person arising from participation in the Program. 5. Provide my consent to receive any medical treatment deemed advisable during participation in the Program and do hereby release and forever discharge City of Sioux Falls and Ecomaniacs any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with the Program. 6. Agree that the release provided in this Release and Waiver is intended to be as broad and inclusive as permitted by law and the Release and Waiver shall be governed by and interpreted in accordance with the laws of the State of South Dakota. I also agree that in the event any clause or provision of this Release and Waiver shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause shall not otherwise affect the remaining provisions of the Release and Waiver. 7. Give my permission to Ecomaniacs to use photographs or photographic images of me participating in the Program in official web sites, newsletters and publications and other materials promoting the Program, as well as, grant and convey unto Ecomaniacs all right, title, and interest in any and all photographic images and video or audio recordings made by Ecomaniacs during participation in the Program.
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