In consideration of being permitted to participate in, or having participated in, a bike helmet fitting station conducted by:
Pike County Health Department, Home Health & Hospice In conjunction with the Eastern Quad County Safe Kids Coalition.
I, for myself, my child, or my personal representatives, assigns, heirs, and next of kin:
1. Acknowledge, agree, and represent that I understand the nature of the activity and that my child and/or I am qualified and in good health and proper physical condition to participate in such activity.
2. Fully understand that:
a. such activity can involve some risk and danger;
b. these risks and dangers can be caused by my child’s own actions or inactions, the actions or inactions of others participating in the activity, the condition in which the activity takes place, or the negligence of the releasees named below;
c. there may be other risks and social and economic losses either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my or my child’s participation in the activity.
d. the bike helmet(s) I receive today is for my child and is not to be given or sold to any person or organization. The bike helmet is fitted to my child specifically and should not be shared with other children or siblings without ensuring proper fit.
3. Hereby release, discharge, and covenant not to sue PIKE COUNTY HEALTH DEPARTMENT, HOME HEALTH & HOSPICE and their respective directors, agents, officers, members, employees, and volunteers from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or part by the negligence of the releasees or otherwise, including negligent rescue operations. I agree not to hold liable or sue Pike County Health Department, Home Health & Hospice or any member thereof, for damages of any sort resulting from the use of any bike helmet distributed at this activities or in future uses following this activity.
4. I further agree that, despite this release and waiver of liability, assumption of risk, and indemnity agreement, if I or anyone on my behalf makes a claim against the releasees, I will indemnify, save, and hold harmless Pike County Health Department, Home Health & Hospice from any litigation, expenses, attorney fees, loss, liability, damage, or cost that may incur as the result of such a claim.