Name of participant (PLEASE PRINT CLEARLY): ______Date Attending Course: ______
WAIVER AND RELEASE OF LIABILITY, ASSUMPTION AND
INDEMNITY AGREEMENT
I understand and acknowledge that by signing below I am legally agreeing to all of the following statements in exchange for being allowed to participate in the activities (the “Activities”) and/or event (the “Event”) at the Shale Hill Adventure Farm, LLC.
I AM AWARE THAT THE ACTIVITIES AND/OR EVENT ARE HAZARDOUS AND THAT I COULD BE SERIOUSLY INJURED OR EVEN KILLED. I AM VOLUNTARILY PARTICIPATING IN THE ACTIVITIES AND/OR EVENT 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.
1.I understand that this Agreement also operates for my spouse, children, parents, guardians, heirs, next of kin and any legal or personal representatives, executors, administrators, successors and assigns, or anyone else who might claim or sue on my behalf (“Related Parties”). I, on behalf of myself and the Related Parties, forever waive, release, discharge and covenant not to sue Shale Hill Adventure Farm, LLC, and its owners, members, managers, representatives, agents and/or employees, subsidiaries and/or assigns, as well as its independent contractors, sponsors, advertisers and volunteers, (hereinafter the “Releasees”), with respect to any and all injury, disability, death, and/or loss or damage to person or property, whether arising from the negligence or misconduct of the Releasees or otherwise.
I hereby assume full responsibility for any risk of bodily injury, death or property damage arising out of or related to participation and/or instruction in the Activities and/or Event, whether foreseen or unforeseen and whether caused by the negligence of the Releasees or otherwise. I hereby separately agree to indemnify and save and hold harmless the Releasees from any loss, liability, damage or cost that they may incur arising out of or related to participation in the Activities and/or Event, whether caused by the negligence of the Releasees or otherwise.
I hereby assume all of the risks of participating in the Activities and/or Event, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the Releasees, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.
2.I understand that I may encounter variations in terrain, which may result in injury or damages. I acknowledge that these are my responsibilities, and I assume all risk for these hazards, including debris, rocks, cliffs, and other hazardous surface or subsurface conditions or obstacles, whether they are obvious or not obvious, man-made or natural. If I observe any unusual and/or significant hazard during my presence or participation, I will remove myself from participation and report such hazard.
3.I acknowledge that this Agreement will be used by the Activities and/or Event Releasees, and that it will govern my actions and responsibilities at said Activities and/or Event. I agree to abide by the rules of the Activities and/or Event, as well as civil, criminal and traffic laws and regulations. I understand that I may be dismissed from the Activities and/or Event if I disobey rules, regulations, directions, instructions or laws, or endanger the safety or negatively impact any person or any property of any kind.
4.I consent to the administration of first aid and any other necessary medical treatment as necessary in the event of injury or illness and hereby release and indemnify Releasees from any and all liability or claims arising out of such treatment.
5.I certify that I am physically fit, have sufficiently prepared or trained for participation in the Activities and/or Event, and have not been advised not to participate by a qualified medical professional. I certify that there are no health-related reasons or problems, which preclude my participation in these Activities and/or Event.
6.I attest that I am covered by medical insurance. I agree to assume liability for any and all medical costs incurred as a result of my participation in the Activities and/or Event that are not covered by my insurance. I agree to indemnify and hold harmless the Releasees from all liability for medical costs.
7.I understand that the Activities and/or Event may be filmed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the Releasees and assigns.
8.I understand that if I withdraw from the Activities and/or Event, I will not be reimbursed for any portion of fees paid, and I understand that all fees for participation are paid in exchange for the opportunity to participate to the best of my ability and in no way reflect an entitlement to complete the Activities and/or Event.
9.I agree that the Releasees may postpone, cancel, or modify the Activities or Event due to weather or other factors beyond their control that might affect the health and or safety of the participants.
10.I attest that I am not, on the date of the Activities and/or Event, under the influence of any alcohol or drugs that would in any way impair my ability to participate. I assume full responsibility for any injury or loss to myself or to others and for any damage to personal or real property associated with my use or consumption of alcohol and/or drugs at any point before or during the Activities and/or Event.
11.If the Activities and/or Event include equestrian activities, I understand that pursuant to Vermont Law, an equine activity sponsor is not liable for an injury to, or the death of, a participant in equine activities resulting from the inherent risks of equine activities that are obvious and necessary, pursuant to 12 V.S.A. § 1039 (attached).
The Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I HAVE READ THIS WAIVER AND RELEASE OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AM AWARE OF ITS LEGAL CONSEQUENCES, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
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Signature of Participant/Student/Competitor Age D.O.BAddress (#, Street or PO Box)
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Printed Name of Participant/Student/Competitor(City, State, Zip)
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DatePhoneEmail
Emergency Contact Name: ______
Emergency Contact Phone Number: ______
If you are a minor (under 18 y.o.), please have parent/guardian sign below:
As a parent and guardian, I am signing this document on behalf of my minor child and agree to be specifically bound to all terms and conditions of this Agreement. I have read the Agreement, fully understand the terms herein, understand that I have given up substantial rights by signing it, am aware of its legal consequences, and have signed this document freely and voluntarily without any inducement. I intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and further agrees to indemnify and save and hold harmless Releasees.
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PRINT Name of Parent/Guardian for Minors 18 & underSignature of Parent/Guardian
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DateEmail