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NOTE: Event captains have the final ruling authority pertaining to rule violations and unsportsmanlike
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All participants must sign a liability waiver prior to competing in
the Community Challenge. Anyone one who fails to complete the
waiver will not be allowed to participate.
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Please cut and copy the attached form as many times as needed; for
all of the participants on you teams.
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Completed forms must be turned into the United Way office by Sept.
8th.
Email: [email protected]
Fax: 937-324-2605
Mail: P.O. Box 59, Springfield, Ohio 45501
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United Way of Clark, Champaign
& Madison Counties
Participant:
____________________________________
Activity:
2016 Community Challenge
Location:
Snyder Park, Springfield, Ohio
Release and Waiver of Liability
I acknowledge that I am assuming a risk of injury by virtue of my participation in the above-referenced activity, and
hereby agree to release, discharge, defend and indemnify United Way of Clark, Champaign and Madison Counties, National Trails
Parks & Recreation, the City of Springfield, OH, its directors, officers, volunteers and employees, from and against any claims,
costs, expenses, liabilities, damages and attorneys fees, including but not limited to claims of bodily injury (including death),
which I may suffer or claim to suffer by reason of my participation in the activity listed above. This release is intended to explicitly
and specifically release the releasees from their own negligence, be it active, passive or gross, or alleged as such. This release
is further intended to cover all derivative claims which arise or may arise out of any events, losses or claims which may arise
hereunder. This release remains in effect unless and until revoked in writing by Participant.
Photo Release
I grant to United Way of Clark, Champaign and Madison Counties (UWCCMC,) its representatives and
employees the right to take photographs and video of me in connection with Community Challenge. I authorize
UWCCMC, its assigns and transferees to copyright, use and publish the same in print and/or electronically.
I agree that UWCCMC may use such photographs of me with or without my name and for any lawful purpose,
including for example such purposes as publicity, illustration, advertising and Web content.
By:
_______________________________
Print name
_______________________________
Sign name
___________________________
Date
________________________________
Address
___________________________
City, State ZIP
Must be signed by parent/guardian if Participant is under the age of 18 at time of signature
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