Town of
I
understand participation in (name of event) ___________________________________
may involve rigorous physical activity and risks of physical injury, and we
assume these risks. I hereby give
consent for emergency transportation and treatment in the event of illness or
injury. I hereby accept responsibility
for the payment of any emergency transportation or treatment on behalf of the
participant. I further certify the
participant is in good physical condition, and has no medical or physical
conditions that would restrict his/her participation in this event.
(Name of
Participant)__________________________________________on this (Date)
_________________, 2008 does hereby covenant and agree to release and hold
harmless the Town of Clay from and against any and all liability, loss,
damages, claims, or actions (including costs and attorney fees) for bodily
injury and/or property damage, to the extent permissible by law arising out of
participation in (name of event):
____________________________________________________________________________________
during
(dates)______________________________________, 2008.
Pictures
and other materials, which include me, may be used for Town of
There is no
medical insurance carried by the Town of
REFUNDS IN
Name:___________________________________________________________________________________________________________
Address:
Medical/Allergy History:
_________________________________________________________________________________________________________________
Additional Person/Phone # to
contact in an emergency:
_________________________________________________________________________________________________________________
Check/Money Order #: ______________________________
Cash Receipt # __________________ Amount Paid:___________________