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LIABILITY WAIVER – OFFICIAL 2014
PARTICIPANT RELEASE OF LIABILITY and ASSUMPTION OF RISK AGREEMENT
In consideration of being allowed to participate in any way in the program, related events and activities, I (PRINT NAME) ________________________________________________ the undersigned, acknowledge and agree that by signing this I will indemnify, defend, and hold harmless trustees, officers, directors, employees and agents, including Principal Sponsors and Organizers (“Indemnitees”) from and against any loss, expense, liability, damage, claim (including reasonable attorneys’ fees)(“Claim”) made or brought on behalf of personal injury, including death, that arises out of participation, a protocol required procedure, or Sponsor’s negligence or willful misconduct and omission. This will include the duration of 17 April 2014 through 27 April 2014, but this coverage will indemnify permanently, giving broad definitions to these statements of protections.
1) I am donating my time and services without any compensation and shall at no time be considered an employee or independent contractor of Principal Sponsors or Organizations. The risks are significant and I assume all risks. I realize that liability may arise from negligence or carelessness on the part of persons or terrain due to dangerous pollution, wildlife, water conditions and high potential to be harmed. I will govern my actions and responsibilities without holding fault to anyone or any entity. I realize I am participating with a program considered dangerous and prone to accidents, (future) illness, permanent paralysis or even death.
2) I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the Releases or others, and assume full responsibility for my participation. If I observe any unusual and/or significant hazard during my presence or participation, I will remove myself and bring such attention of the nearest event sponsor immediately.
3) I, for myself and on behalf of my heirs, personal representatives and next of kin, hereby release, indemnify, and hold harmless Save Maumee, its director, officers, agents, employees, property owners, other volunteers, representatives, sponsors, advertisers, and/or partners used to conduct an event. I am refusing to sue any person or entity for any and all claims, demands, losses and liability arising out of or related program participation, whether arising from the negligence of the Releases or otherwise. This document is construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. We are all volunteers, here to improve our water and identify potential problems in and along the Maumee River and the Maumee Watershed Basin.
4) I hereby consent to receive medical treatment that may be deemed advisable or necessary in the event of injury, accident, and (or) illness that may be caused from this event. I will be responsible for the payment if such situation arises.
5) I grant Save Maumee and all representatives (in all capacities) the right to take photographs and videos at this event, of myself and any minor participants for which I am the parent or guardian. Save Maumee is authorized to use the photographs, video or film, with or without names, for any lawful purpose and may publish the same in print and/or electronically with Board discretion.
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 and willingly agree to comply.
_________________________ Print Participants Name _________________________ Signature (by signing I agree to ALL)
1st EMERGENCY CONTACT NAME/EMERGENCY CONTACT PHONE/ ADDRESS
2nd EMERGENCY CONTACT NAME / PHONE / ADDRESS
3rd EMERGENCY CONTACT NAME / PHONE
_______CONFIRMATION I have read ALL material presented to me, at Orientation and/or on my own regarding the OFFICIAL SAFETY PLAN – I understand this information, and will designate my actions , according to this Plan, to the best of my abilities.
_______I claim personal and financial responsibility for my actions, lack of actions, and use of borrowed equipment.
_______I understand that wearing my Personal Flotation Device (PFD) is most prudent but I MUST have the PFD within my reach at all times, while on the water, as required by Indiana and Ohio Paddle Laws.
_______I knowingly understand that this river has more potential for harm, due to the State and Federal designation under the 303 (d) list of impaired waterways in the United States, and understand that the time of year in which we are paddling has the potential for high, fast moving, cold water; besides the usual potential for drowning, hypothermia, injury or death when paddling on any waterway.
_______Please CONFIRM you are able to do this: Jump feet-first into water over your head. Swim 75 yards in a strong manner using one or more of the following strokes:sidestroke, breaststroke, trudgen, or crawl; then swim 25 yards using an easy resting backstroke. The 100 yards must be swum continuously and include at least one sharp turn. Float by resting face-up in the water for 15 minutes.
________I consent to medical treatment deemed necessary by on-site medics – and if the need arises to check into a hospital or clinic and/or call an ambulance, this will be decided upon by the Medics
________I understand and that I will be filmed and photographed at this event, and event sponsors will use this data and produce materials for education and outreach
________I will be PRESENT or OFFICIALLY check-in at each Landing Location upon Sweep Boat’s arrival
________I understand that my valuables and property will probably get wet, I will take full responsibility for their protection and loss due to water and/or becoming lost.
______________________________________________LIST CANOE BUDDY HERE – DON’T HAVE ONE? no problem, someone will be pairing you with a buddy
__________________& ____________________PEOPLE’S NAME(S) of your buddy BOAT – DON’T HAVE ONE? – no problem, someone will be pairing you with a buddy BOAT
YOUR Cell Phone: (if applicable) _________________________________
MY BUDDY’s cell phone # ________________________________
MY BUDDY BOAT’s cell phone # ___________________________
I have programed into my phone or device (if applicable):
____________ABIGAIL KING – WATER ADMINISTRATOR # 260-417-2500 – text or call
____________JAIN YOUNG – LAND ADMINISTRATOR # 425-213-7516 – text or call
____________LAND MEDIC #
____________WATER MEDIC #
____________ KAREN EWING – WEATHER WATCHER 260-402-5868
If you are holding a smart device or geo-spacial location data device, send that information to:
#1 DON CROY
____________text picture: 260-466-1852
AND / OR
#2 ERIC STAHLSMITH
___________text picture: 317-408-0116
Food Preferences AND Food Allergies (vegan, veggie, omnivore)
Health Problems LIST ALL (allergies, asthma, diabetes, seizures communicable diseases etc)?
Special conditions or medications for disclosure purposes, to help you in-case of emergency?
Personal safety equipment you are able to provide in addition to our community supplies?
DO you hold a licensure, degree, or specialized expertise that we can use for promotion