2016 Panguitch Ice Fishing Derby
January 2 – February 27
Panguitch Lake
Name: ______
Mailing Address:______
City: ______State: ______Zip: ______
Date of Birth: ______Phone Number: ______
Email Address: ______
If under age 12: Age: ______UT Fishing License Number: ______
Parent Name: ______Parent Phone Number: ______
By entering this contest, I acknowledge that I have read and agree to follow and comply with all applicable laws, regulations, and contest rules.
RELEASE OF CLAIMS
For and in consideration of being allowed to participate in the PANGUITCH ICE FISHING DERBY being undertaken at Panguitch Lake, Garfield County, State of Utah, and further realizing that I am participating in an activity for which I may be injured, I on behalf of myself, my heirs, and assigns, do hereby release and forever discharge the PANGUITCH MAIN STREET and its principals, agents, representatives, and insurance carriers, if any, from any and all rights, claims demands, damages, or causes of action, of any kind, known or unknown, existing or arising in the future, resulting from any participation in the above described activities which injuries and/or death may arise in the future from an accident which may occur in connection with the above activities.
Dated this ______day of ______,20______
______
Participant
______
Signature of Parent/Guardian if Participant is under 18
**Email Forms to or fax to 435-676-2758 or mail to PO Box 858, Panguitch, UT 84759**
**Any Questions call Kevin Moore @ 435-690-1024**
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
I, ______(AParticipant@), acknowledge that I have voluntarily applied to participate in the following activities in Panguitch City/Garfield County:
______
(Description of activities which participant will engage in)
I AM AWARE THAT THESE ACTIVITIES ARE HAZARDOUS ACTIVITIES AND THAT I COULD BE SERIOUSLY INJURED OR EVEN KILLED. I AM VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES WITH KNOWLEDGE OF THE DANGER INVOLVED AND AGREE TO ASSUME ANY AND ALL RISKS OF BODILY INJURY, DEATH OR PROPERTY DAMAGE, WHETHER THOSE RISKS ARE KNOWN OR UNKNOWN.
I verify this statement by placing my initials here: ______
Parent or Guardian=s initials (if under 18): ______
As consideration for being permitted by the City, the State of Utah (AState@), the County of Garfield (the ACounty@), and any lessor of the City premises, (ALessor@), to participate in these activities and use the City premises and facilities. I forever release to the City, the State, the County, the Lessor, any affiliated organization, and their respective directors, officers, employees, volunteers, agents, contractors, and representatives (collectively AReleasees@) from any and all actions, claims, or demands that I, my assignees, heirs, distributees, guardians, next of kin, spouse and legal representatives now have, or may have in the future, for injury, death, or property damage, related to my (1) my participation in these activities, (2) the negligence or other acts, whether directly connected to these activities or not, and however caused, by any Releasee, or (3) the condition of the premises where these activities occur, whether or not I am then participating in the activities. I also agree that I, my assignees, heirs, distributees, guardians, next of kin, spouse and legal representatives will not make a claim against, sue, or attach the property of any Releasee in connection with any of the matters covered by the foregoing release.
I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND THE CITY, COUNTY, THE STATE, AND THE LESSOR, AND SIGN IT OF MY OWN FREE WILL.
If Signed by a Parent or Guardian: I verify that the dangers of the activities and the significance of this release and Waiver were explained to the Participant and that the Participant understood them.
Executed at ______, Garfield County, Utah on ______, 200__.
PARTICIPANT/RELEASOR PARENT/GUARDIAN
______
Signature, address, phone number: Signature, address, phone number: