Disclaimer
School District of Luck
Release of Liability and Assumption of Risk Agreement
This form is a release of liability form.
This release of liability form clearly states you are fully aware that you are going to take part in an
exercise program. As a direct consequence of the inherent risks involved in taking part in this activity,
you know it is possible that you may incur injury. By signing this form, should any injury occur, you fully
understand and agree that neither you, nor your relatives nor any other family representatives, can make
a claim, sue, or expect Luck School or its employees to be legally responsible or pay for any damages.
Please read the following document carefully and ensure you understand it fully before signing it.
Acknowledgement and acceptance of risks:
I, the undersigned, hereby acknowledge that I have voluntarily chosen to take part in this exercise
program. Certain risks are inherent in any such activity and cannot be fully eliminated, precluded, or
controlled. I appreciate that these risks, some of which can contribute to the unique character and
enjoyment of the activity, can also be the cause of injury.
By my signature, I hereby explicitly acknowledge, accept and willingly assume all risks and
hazards related to, arising out of, or associated with my participation in the exercise program.
** Parent signature is required if participant is under age 18.
Risk Release:
The School District of Luck always reserves the ultimate right, at any time, to accept, deny or terminate
participation to and by any person. I hereby agree to follow all rules, regulations, and the instructions of
the School District of Luck and its employees while participating in this program. I also certify that I am
physically, mentally and emotionally capable of participating in these activities. I hereby represent that I
have informed the School District of Luck of any pertinent medical conditions that may affect my
participation in this program.
PLEASE NOTE:
ALL PARTICIPANTS MUST FILL OUT THIS ENTIRE FORM. All participants under the age of 18 years
must have the form signed by the minor's parent or guardian prior to participating in this program.
If you have any questions regarding this form, please contact Amy Aguado, Luck School District
Community Education director at 715-472-2152 ext. 103. Please specify if you’d like to receive a copy;
otherwise the original will be kept at Luck School.
PLEASE PRINT CLEARLY - Thank You!
Participant Name _____________________________________________________ Date ____________________
Home Phone ____________________ Work Phone ___________________ Cell Phone _____________________
Address ________________________________________ City ________________ State ______ Zip__________
Signature _______________________________________ Rec’d by _____________________________________
** Parent / Guardian Signature if Participant is under 18 _______________________________________________
Release of Liability form // Fitness Center // A. Aguado