March 26-29, 2009
HOSTED BY THE CORPS OF CADETS AT MARION MILITARY INSTITUTE
Release, Waiver, and Authorization for Medical Treatment (Must be signed by student and parent/guardian and returned by all participants)
I, participant (or participant's parent/legal guardian if participant is under 18 years old) _____________________________________, authorize my (child's) full participation in the Knight-Fox Challenge, including related activities which may include an obstacle course, on March 13-16, hosted by Marion Military Institute. I understand the activities are not without some inherent risk of injury. In consideration of my (my child's) right to participate in this activity I agree to release, waive, discharge, agree not to sue, and agree to hold harmless for any and all purposes Marion Military Institute, and its Board of Advisors, and their officers, employees, agents and volunteers (Releasees) from any and all liabilities, claims, or injuries, including death, that may be sustained while participating in this activity, including traveling to, from, and for the activity, or while on premises owned or controlled by Releasees, including injuries sustained as a result of the negligence of Releasees. I understand this release does not apply to injuries caused by intentional or grossly negligent conduct on the part of Releasees. I further agree to indemnify and hold harmless Releasees for any loss , liability, claim, or injury caused by me (my child) while participating in this activity, including traveling to, from, and for the activity, or while on premises owned or controlled by Releasees.
I also give my permission for me (my child) to receive any emergency medical treatment by a healthcare professional, including emergency medical transportation, which may be required for injuries sustained by me (my child.) I agree to indemnify and hold harmless Releasees for any costs incurred to treat me (my child), even if a Releasee has signed hospital documentation promising to pay for the treatment.
Participant Full Name: ________________________________
Personal Insurance Company & Policy Number ______________________
I also agree to follow all instructions and procedures in order to maintain a maximum level of safety.
Participant's Signature: _________________________ Date: _____________
Parent/Guardian Signature________________________Date _____________
(Required if participant is younger than 18)
State law requires you to be informed of the following:
(1) you are entitled to request to be informed about the information about yourself collected by use of this form (with a few exceptions as provided by law);
(2) you are entitled to receive and review that information; and
(3) you are entitled to have the information corrected at no charge to you.
You must mail or fax this form to our office (334) 683-2383 not later than March 23, 2009. Or, you may bring this form with your Knight-Fox. This form will be required at check-in to particpate in our program.
KNIGHT-FOX CHALLENGE
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