Clinic Waiver and Emergency Contact Info
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Parent/Guardian Name (if applicable)
Mobile phone number
Participant Information
Participant name *
E-mail address *
Please note any medical issues your instructor needs to be aware of (allergic to bee stings, asthma, etc...)
Date of clinic
MM
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DD
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YYYY
Emergency Contact Information
Emergency Contact Name
Emergency Contact Mobile Phone Number
Emergency Contact Relationship (wife/husband/girlfriend/parent)
Waiver and Release
WAIVER AND RELEASE OF LIABILITY, PHOTO RELEASE -- READ BEFORE SIGNING

In consideration of being allowed to participate in any way in the cycling program, its related events and activities, I,______________________________, the undersigned, acknowledge, appreciate, and agree that:

The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, FOREVER DISCHARGE, INDEMNIFY, AND HOLD HARMLESS John C Raisch, YJR Outdoors and Yo! Just Ride, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, vendors, contractors, advertisers, and, if applicable, owners and lessors of premises used for the activity ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

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; and,

I willingly agree to comply with the stated and customary 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 Company immediately;  and,

Photo Release - I willingly give permission to John Raisch, to take and use testimonial comments, photographs, and/or video relating directly and indirectly to me, my family, or subjects under my control, and to copyright, exhibit, reproduce, publish, or distribute them at any time for promotion. I also release and discharge each of the above parties from any claims or demands in any way relating to the use of these photographs/videos; and,

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.


X__________________________________________________ Age:________    Date Signed:_____________
             PARTICIPANTS SIGNATURE


FOR PARENT/LEGAL GUARDIAN OF PARTICIPANTS OF MINORITY AGE

This is to certify that I, as parent/legal guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.


X_________________________________________________________            Date Signed: ___________
     PARENT/LEGAL GUARDIAN SIGNATURE
     (print name)
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