8/8/2019 KaVroom Waiver Form 2011

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MRSS Ka-Vroom 2011Soapbox Derby

(June 18th, 2011)

RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKSAND INDEMNITY AGREEMENT

ATTENTION: BY SIGNING THIS FORM YOU ARE ACCEPTING THE RISKS INVOLVEDIN PARTICIPATING IN KA-VROOM!

PLEASE READ CAREFULLY! ALL PARTICIPANTS MUST BE AGES 5-14

NAME OF PARTICIPANT: ______________________________________________________________________________

NAME OF PARENT OR GUARDIAN: ____________________________________________________________________

ADDRESS OF PARTICIPANT:___________________________________________________________________________

TELEPHONE NO (1): _____________________________________ BIRTH DATE: _____________________

TELEPHONE NO (2): _____________________________________

EMAIL OF PARENT OR GUARDIAN (1):_________________________________________________________________

EMAIL OF PARENT OR GUARDIAN (2):_________________________________________________________________

DISCLAIMER CLAUSE

Ka-Vroom, its volunteers, and representatives (furthermore to be known as the Ka-Vroom Team

and representing Maple Ridge Secondary School) are not responsible for any injury, loss or damage

of any kind sustained by any person while participating in Ka-Vroom.You are entering in this event

at YOUR OWN RISK.

INDEMNIFICATION AND RELEASE OF LIABILITY

In return for the Ka-Vroom Team allowing my child to voluntarily participate in the Ka-Vroom and

related activities, I agree:

1. TO ASSUME AND ACCEPT ALL RISKS arising out of, associated with, or related to my

participating in the Ka-Vroom event;

2. TO BE SOLELY RESPONSIBLE FOR ANY INJURY, LOSS OR DAMAGE which I

might sustain while participating in Ka-Vroom;

3. TO HOLD HARMLESS AND INDEMNIFY THE KA-VROOM TEAM:

a) From any and all liability for any damage to the personal property of, or personal injury to,

any third party resulting from my participation in Ka-Vroom and all related activities; and

b) From any and all claims, demands, actions and costs that might arise out of my participating

in the Ka-Vroom event.

PERMISSION TO USE PHOTOGRAPHS

In return for the Ka-Vroom Team allowing my child to participate in this event, I give the Ka-

Vroom Team permission to use his/her photographs for promotional purposes including, but not

limited to, a promotional video/newsletter. I acknowledge that by signing this form, the Ka-Vroom

Team can publish photographs of myself or my child without any further notification.

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8/8/2019 KaVroom Waiver Form 2011

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Protection of Privacy -The personal information requested on this form will be protected. It willbe used for the purpose of implementing this waiver. Direct any questions about this collection to: Karen Aitken(Ka-Vroom Coordinator) or the MRSS Ka-Vroom Team atEmail: kavroommrss@gmail.comPhone: (604) 463-4175 ext. 1119

Signed this _______ day of ______________________________, 20____

__________________________________________ ________________________________________

Signature of Participant Signature of Parent/Guardian

__________________________________________ ________________________________________

Printed Name of Participant Printed Name of Parent/Guardian

_______________________________________________________________________________Note: Document must be copied to a single page back to backwhen used.Signed documents must be brought to MRSS (Maple Ridge Secondary School) upon signing.For more information, visit the official Ka-Vroom Website: mrsska-vroom.blogspot.comUpdated: November, 2010

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