Sport____________
ACKNOWLEDGEMENT OF RISK AND HOLD HARMLESS AGREEMENT
Athletic Event Date & Location: ______________________________________________________
I hereby acknowledge that I have voluntarily chosen to participate in the above authorized Central Washington University athletic
event (hereafter identified as “the Activity”), which may involve independent travel to and from the Activity location in my own or
someone else’s personal vehicle.
I understand and acknowledge that the Activity may involve risk of injury or loss, and I agree to accept and assume any risks
associated with the Activity and with travel to and from the Activity, including but not limited to property damage or loss, bodily
injury, and death, whether caused by my own actions or by those of others.
I understand that Central Washington University does not provide any insurance coverage with respect to my independent travel to
and from the Activity and that I am solely responsible for any loss or expense resulting from my participation. I further understand,
if I am driving my own vehicle in connection with the Activity, that I am responsible for complying with all applicable state laws
regarding the operation and insurance of a motor vehicle.
Being fully aware of the possible consequences of my participation in the above named Activity, and as a condition of my
participation, I hereby acknowledge and assume responsibility for all such risks, foreseen or unforeseen, and agree to hold harmless
the State of Washington, Central Washington University, its officers, agents, employees and volunteers, from any and all
responsibility or liability for any injuries or loss arising out of my participation in the Activity. I further understand and agree that
this assumption of risk and release of claims is intended to be as broad and inclusive as permitted by the laws of the State of
Washington and that, if any portion hereof is held invalid, the remainder shall nonetheless be given full effect.
I have read and understand this acknowledgement of risk and hold harmless and agree to sign it voluntarily.
Participant's Signature: ___________________________________________________
(Parent or legal guardian if under the age of 18)
Date: ________________
Parent’s Signature: ___________________________________________________
(Parent or legal guardian’s signature required regardless of age)
Date: ________________
Participant’s Name:
(Please Print)
__________________________________________________________________
__________________________________________________________________
Address:
Phone Number:
__________________________________________________________________
__________________________________________________________________
Emergency Contact:
__________________________________________________________________
Phone:
Approved as to form only, by Alan Smith, Assistant Attorney General, January 21, 2010.