Adult Medical Release Form and Waiver / Hold Harmless Agreement

  • Adult Medical Release Form and Waiver / Hold Harmless Agreement

  • Party Information

  • Date Format: MM slash DD slash YYYY

  • Emergency Contact Information

  • In consideration of being allowed to participate in any way for its related events and activities, I acknowledge, appreciate, and agree that: The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may re-duce this risk, the risk of serious injury does exist; and, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove my-self from participation and bring such to the attention of the Company immediately; and, I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessor’s of premises used for the activity ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation,WHETHER ARISING FROM THE NEGLIGENCE OF THERELEASEES OR OTHERWISE, to the fullest extent permitted by law

    I request that if I am incapacitated during TMRS INC’s activities that I be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians and staff, duly licensed as Doctors of Medicine or other such licensed technicians or nurses, to perform any diagnostic treatment of the above party. I have not been given a guarantee as to the results of examination or treatment. I authorize the medical facility to dispose of any specimen or tissue taken from the above named party. In addition, I hereby give TMRS INC permission to publish test results, of which I may be included in whole or in part. I give my consent without reservation to publish and test results on our website, in brochures, promotional materials or any other documents utilized to further the mission and goal of TMRS INC as defined in our mission statement.

    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

  • Date Format: MM slash DD slash YYYY