Contact:  Mike & Lori Beinlich   campmaplelake@gmail.com    

570-419-4907

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Word Document

 

 

WAIVER AND RELEASE OF LIABILITY, MEDICAL CONSENT AND

     ASSUMPTION OF RISK    

 

     In consideration of being allowed to participate in the Camp Maple Lake (including but not limited to) Schools, any seminar, clinic, exhibit, or demonstration conducted in connection therewith (the Event), the undersigned attendee hereby expressly waives and releases  Camp Maple Lake its administrators, directors, medical staff, certified athletic trainers, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors of premises in which the activity takes place from any liability, losses, damages, injuries (including disability or death) actions and all causes of action or claims whatsoever, of any kind or nature, arising from, or in any manner related to, attendee's participation in the Event.

            This Waiver and Release shall inure to the benefit of the assigns or successors of Camp Maple Lake and shall be binding upon the heirs or successors of attendee. Attendee specifically understands that attendance at or participation in any activity is at attendee's own and sole risk.  Attendee specifically acknowledges his/her experience and capabilities and believes he/she is qualified to participate in any such activity offered by Camp Maple Lake Attendee fully understands that participation in any function or activity set forth herein involves risks and dangers and may result in serious bodily injury, including permanent disability, paralysis, and/or death.  Attendee understands that such risks and dangers may be caused by his own actions, or inaction, the actions or inaction of others participating in the activity, the condition in which the activity takes place or the negligence of the releases, specifically Camp Maple Lake and its agents or employees.  With full knowledge, the attendee fully accepts and assumes all such risks and all responsibility for losses, costs, and damages incurred as a result of his participation in the Event, of any kind or nature whatsoever.  Attendee further agrees that if, despite this release, he/she or anyone on his behalf makes a claim against any of the releasees named herein, attendee will indemnify, save and hold harmless each of the releasees from any litigation expenses, attorney's fees, loss liability, damage, injury (including disability or death) or cost any of them may incur as a result of any such claim.

            Attendee acknowledges that by registering for this Camp Maple Lake Event, he/she and parent or guardian has read this agreement, fully understands it terms, understands that he/she has given up substantial rights by signing it, and has signed it freely and without any inducement or assurance of any nature, and intends same to be a complete and unconditional release of all liability to the greatest extent allowed by the law of the state in which such activity is conducted and, further, agrees that if any portion of this agreement is held to be invalid that the balance, notwithstanding, shall continue in full force and effect.

 

 

     This Agreement shall be binding upon and shall inure to the benefit of each of the parties and their respective heirs, successors and permitted assigns.
     IN WITNESS WHEREOF, the parties hereunto set their hands and seals on the dates shown below and on the counterpart signature pages attached hereto.

CONSENT TO TREATMENT:

In the event of any accident, sudden illness, or medical emergency involving Attendee in connection with a Camp Maple Lake Event, I hereby authorize the Certified Athletic Trainer, leadership and staff members of Camp Maple Lake to consent for any and all emergency and non-emergency medical treatment as may be deemed appropriate under the existing circumstances and consent to an x-ray, C-Scan, MRI, examination, consultation, local or general anesthetic, medical or surgical diagnosis or treatment and hospital care deemed to be necessary by a licensed physician, and agree to accept full financial responsibility for these services.

 

 

I HAVE READ THIS RELEASE OF LIABILITY, MEDICAL CONSENT AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

 

X_____________________________________________                                   DATE SIGNED: _____________

{ PARTICIPANT'S SIGNATURE}

 

FOR PARTICIPANTS OF MINORITY AGE
{UNDER THE AGE OF 18 AT THE TIME OF REGISTRATION}


This is to certify that I, as parent / guardian with legal responsibility for this participant, do consent and agree to his / her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation Camp Maple Lake programs as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE.

 

X_____________________________________                Emergency Phone: __________________________                  

 

DATE SIGNED: _______________________
{PARENT / GUARDIAN SIGNATURE}