Event Waiver Form
Event Name
Event Starting Date
-
Month
-
Day
Year
Date
Event Ending Date
-
Month
-
Day
Year
Date
Personal & Contact Information
Name
First Name
Last Name
Age
Example: 23
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
If there is any health conditions, please explain
Astma, diabetes, allergies, medications
Is there any activity restrictions?
Yes
No
If yes, Please explain
Health Insurance
Do you have any health insurance?
Yes
No
Insurance Company
Policy Number
Policy Holder
Release
I, undersigned, agree with the following statements
Medical Release: Between starting and ending of the event, as deemed necessary,I authorize activity holder to select the hospital or dentist for hospitalization, to secure proper treatment, and/or order an injection, anesthesia, or surgery, for the person specified above.
Liability Release: Even with the best of planning and precaution, unforeseen events can occur. By signing this form, I agree to assume and accept all risks and hazards inherent in the activities. They also agree not to hold activity holder or its employees or volunteer assistants liable for damages, losses, or injuries to the person or property undersigned.
The undersigned hereby waive, release and forever discharge Live Alkaline Water Properties, LLC, Tamare Farm/Campground, its affiliates, managers, members, agents, attorneys, employees, staff, volunteers, heirs, executors, administrators, representatives, predecessors, successors and assigns from any claims resulting from physical or personal injury, pain, suffering, illness, disfigurement, temporary or permanent disability, loss or death, and any property damage that may occur caused by fire, theft, vandalism, water or land-related accidents, natural events or any other occurrences or mishaps. We are here of our free will, and entirely at our own risk. We understand that these injuries or outcomes may arise by our own or others’ negligence or conditions on the premises or the conditions or our use of amenities offered at the premises or related to travel to and from the premises. Nonetheless, we assume all related risks, both known and unknown. Live Alkaline Water Properties, LLC, Tamare Farm/Campground, is not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity. I fully understand that this is a release of liability and I agree to voluntarily give up or waive any right that I otherwise have to bring legal action against Live Alkaline Water Properties, LLC, Tamare Farm/Campground, for any personal injury or property damage whatsoever for negligence on the part Live Alkaline Water Properties, LLC, Tamare Farm/Campground, its agents and employees. This waiver and release of liability shall remain in effect for the duration of my presence at the premises.
We further agree to indemnify, defend and hold harmless Live Alkaline Water Properties, LLC, Tamare Farm/Campground, against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related costs.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: