Microsoft Word - Waiver MWD SLC 2015.docx - SHAPE America



?RELEASE AND WAIVER OF LIABILITY AGREEMENT SHAPE America Midwest District Student Leadership Conference October 1-?‐3, 2015 -?‐ Pokagon State Park, Angola, IN ?I ?agree ?and ?acknowledge ?that ?I ?am ?undertaking ?participation ?in ?the ?2015 ?SHAPE ?America ?Midwest ?District ?Student ?Leadership ?Conference ?(Student ?Leadership ?Conference) ?events ?and ?activities ?by ?my ?own ?free ?and ?intentional ?act, ?and ?I ?am ?fully ?aware ?that ?possible ?physical ?injury ?might ?occur ?to ?me ?as ?a ?result ?of ?my ?participation ?in ?these ?events. ? ?I ?give ?this ?acknowledgement ?freely ?and ?knowingly ?and ?that ?I ?am, ?as ?a ?result, ?able ?to ?participate ?in ?the ?Student ?Leadership ?Conference ?events ?and ?I ?do ?hereby ?assume ?responsibility ?for ?my ?own ?well-?‐being. ? ?I ?also ?agree ?not ?to ?allow ?any ?other ?individual ?to ?participate ?in ?my ?place ?unless ?authorized ?by ?SHAPE ?America. ? ?This ?acknowledgement ?includes ?my ?guest(s) ?participation ?(if ?applicable) ?in ?any ?events. ? ?SHAPE ?America ?plans ?to ?take ?photographs ?at ?the ?Student ?Leadership ?Conference ?and ?reproduce ?them ?in ?SHAPE ?America ?educational, ?news ?or ?promotional ?material ?whether ?in ?print, ?electronic ?or ?other ?media, ?including ?the ?website. ? ?By ?participating ?in ?the ?Student ?Leadership ?Conference, ?I ?grant ?SHAPE ?America ?the ?right ?to ?use ?any ?image, ?photograph ?and ?biography ?of ?me ?or ?my ?guest(s) ?for ?such ?purposes. ? ?All ?postings ?become ?the ?property ?of ?SHAPE ?America. ? ?Postings ?may ?be ?displayed, ?distributed, ?or ?used ?by ?SHAPE ?America ?for ?any ?purpose. ? ?If signed by a Parent or Guardian: ?I ?verify ?that ?the ?dangers ?of ?the ?activities ?and ?the ?significance ?of ?this ?waiver ?were ?explained ?to ?the ?Participant ?and ?that ?the ?Participant ?understood ?them ?and ?that ?I ?agree ?to ?the ?terms ?of ?the ?policy ?and ?waiver ?on ?behalf ?of ?my ?minor ?child. ? ?If ?you ?are ?under ?18 ?years ?of ?age, ?you ?and ?your ?Parent ?or ?Guardian ?must ?sign ?this ?form ?where ?indicated. ? ? ? ?PARTICIPANT PARENT OR GUARDIAN ? Date: ____________________ Date: ____________________ ? Signature: ______________________________ Signature: ____________________________ ? Name: ______________________________ Name: ____________________________ ? Address: ______________________________ Address: ____________________________ ? ? ______________________________ ____________________________ ? ................
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