Sie sind auf Seite 1von 3

Boehms United Church of Christ 571 Penllyn Blue-Bell Pike, Blue Bell, PA 19422 (215) 646-6132 ACCIDENT WAIVER

AND RELEASE OF LIABILITY Description of Activity: __________________________________________ Telephone or Cell #: ____________________________ Participant's Name (print): __________________________________________________ Home Address: ___________________________________________________ City _________________________State ________________ In consideration of Boehms United Church of Christ opening its premises for use, recreational, tours, etc., it is agreed: 1. ACKNOWLEDGEMENT OF RISK (General): To the best of my knowledge, I am fully able to participate in this activity. I am fully aware of the risks and hazards connected with the activity including, but not limited to, the risks as noted herein and I hereby elect to voluntarily participate in said activity and to enter the above-named premises and engage in such activity knowing that the activity may be hazardous to me and my property. I voluntarily assume full responsibility for any and all risks of loss, property damage or personal injury, including loss of limbs and death, that may be sustained by me or my property as a result of being engaged in such an activity, whether caused by myself, other participants or negligence of Boehms United Church of Christ. I understand it is an old building and fully accept responsibility for the risks involved including, but not limited to, narrow stairs, darkness, etc. 1a. ACKNOWLEDGEMENT OF RISK (Athletic): I acknowledge that athletic activities can be an extreme test of a persons physical and mental limits and carries with it the potential for but not limited to: sickness, emotional injury, personal injury, death, serious injury, financial damage and property/damage loss. The risks include, but are not limited to, those caused by facilities, temperature, weather, condition of athletes, equipment, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, and lack of hydration. These risks are not only inherent to athletics, but are also present for volunteers. 2. ASSUMPTION OF RISK: I hereby assume all of the risks of participating in events involving the use of Boehms United Church of Christs premises. I realize that liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault.

3. ACKNOWLEDGEMENT OF PHYSICAL FITNESS: I certify that I am physically fit, have sufficiently trained for participation in the event and have not been advised otherwise by a qualified medical person. 4. WAIVER AND RELEASE OF LIABILITY: I acknowledge that this Accident Waiver and Release of Liability form will be used by Boehms United Church of Christs, sponsors and organizers of the event in which I may participate, and that it will govern my actions and responsibilities at said events. In consideration of Boehms United Church of Christs permitting me to participate in events on their property, I hereby sign this release of liability for myself, my executors, administrators, heirs, next of kin, successors, and assigns and (A) Waive, Release and Discharge Boehms United Church of Christs from any and all liability for my death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter occur to me including my traveling to and from this event; and THE FOLLOWING ENTITIES OR PERSONS: The directors, officers, employees, volunteers, representatives, and agents, the event holders, event sponsors, event volunteers; (B) Indemnify and Hold Harmless the entities or persons mentioned in the above paragraph from any and all liabilities or claims made as a result of participation in this event, whether caused by the negligence of releases or otherwise. I accept personal financial responsibility for any injury or other loss sustained while on the premises of Boehms United Church of Christs or in transportation to and from said premises for said event. 5. CONSENT TO RECEIVE MEDICALTREATMENT: I hereby consent to receive medical treatment that may be deemed advisable in the event of injury, accident and/or illness during this event. The Accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. If I desire to reject any and all medical treatment, I must so indicate in this form when signed. 6. PHOTO RELEASE: I understand that at this event or related activities, I may be photographed. I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and assignees. 7. ACKNOWLEDGEMENT AND SIGNATURE: I hereby certify that I have read and approve this document; and, I understand its content.

Signature _______________________________________ Date __________________ Print Name:__________________________________ Witness:______________________________________ Date:___________________

OPTIONAL: REJECTION OF MEDICAL TREATMENT: I hereby reject any and all medical treatment that may be given or offered to me for any reason arising out of my participation in the events that include use of the premises of Boehms United Church of Christs:

Signature _______________________________________ Date __________________ Witness:______________________________________ Date:___________________

PARENT / GUARDIAN WAIVER FOR MINORS (Under 18 years old) The undersigned parent and/or legally appointed guardian does hereby represent that he/she is, in fact, acting in such capacity and agrees to save and hold harmless and indemnify each and all of the parties referred to above from all liability, loss, cost, claim or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian. __________________________________________ Print Name of Parent or Guardian __________________________ Date

_______________________________________________________________ Signature of Parent or Guardian Witness:______________________________________ Date:___________________