Powhatan Youth Wrestling and Community Development Inc., Blackhawk Gym, Cowbuck LLC,
2515 Anderson Highway, Powhatan, Virginia, 23139
IN CONSIDERATION of being permitted to participate in any way, in any event, program, service offered and or provided, camp, clinic, tournament, physical training, weight training, wrestling, lacrosse, basketball, karate or related activity, (“ACTIVITY”) at any time during the calendar year or duration of membership, or scheduled activity I, for myself, my personal representatives, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of the Activity and that I am qualified, in good health, and in proper physical condition to participate in such Activity, I further agree and warrant that if, at any time, I believe the conditions be unsafe, I will immediately discontinue further participation in the Activity. To include when participating in Activities during staffed hours of operation and or non-staffed hours of operation, when access is granted to or as a part of the membership agreement, which includes 24 hour access by means of special membership pass keys and/or codes to access the facilities which is membership specific and may be revoked at any time the agreement of the 24 hour access is violated.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH (“Risks”); (b) these Risks and dangers may be caused by own actions or inactions of others participating in the Activity, the conditions in which the Activity takes place, or THE NEGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be OTHER RISKS or SOCIAL AND ECONOMIC LOSSES, either unknown to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation, or that of the minor, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their administrators, directors, agents, officers, members, volunteers, employees, other participants, officials, rescue personnel, sponsors, advertisers, owners and lessees of premises on which the Activity is conducted, (each of the forgoing shall be considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES OR DAMAGES ON MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost in which may be incurred as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINTED NAME OF PARTICIPANT
__________________________________________________________________________________
PARTICIPANT’S SIGNATURE _________________________________________________________________________________
PHONE ______________________________________________ DATE ___________________________________________
Top section completed by person under 18 to include the completion of the below section by Parent/Guardian for any participant under the age 18.
MINOR RELEASE AND I, THE MINOR’S PARENT AND/OR GUARDIAN, UNDERSTAND THE NATURE OF THE ACTIVITY AND THE MINORS EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEE’S FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR’S ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED , IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE “RELEASEES” OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND FURTHER AGREE THAT IF, DESPITE THIS RELEASE, I, THE MINOR, OR ANYONE ON THE MINORS BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED ABOVE, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR ANY COST THAT MAY OCCUR AS A RESULT OF ANY SUCH CLAIM.
PRINTED NAME OF PARENT/GUARDIAN _______________________________________________________________________
PARENT/GUARDIAN SIGNATURE (only if participant is under the age of 18) ___________________________________________
PHONE _____________________________________________ DATE ___________________________________________