Medical Release Waiver
Medical Release Waiver
I. Participant Information:
Name: [YOUR NAME]
Date of Birth: 10/02/2050
Address: Durham, NC 27701
Phone Number: 222 555 7777
Emergency Contact: Patricia Hill
Emergency Contact Information: 222 555 7777
II. Event/Activity Information:
Event/Activity: North Carolina Charity Fun Run
Date: 12/20/2067
Location: Durham, NC 27701
III. Acknowledgment of Risks:
I, [YOUR NAME], acknowledge that participation in the North Carolina Charity Fun Run involves inherent risks including, but not limited to, physical injury, illness, or property damage. I understand that these risks may arise from activities such as running long distances and navigating uneven terrain.
IV. Voluntary Participation:
I voluntarily choose to participate in the North Carolina Charity Fun Run and agree to assume all risks associated with the event. I understand that it is my responsibility to consult with a physician regarding my fitness for participation.
V. Release of Liability:
In consideration of being allowed to participate in the North Carolina Charity Fun Run, I hereby release and hold harmless [YOUR COMPANY NAME], its officers, employees, agents, and volunteers from any and all claims, liabilities, or causes of action arising out of or in any way connected with my participation in this event, including any claims for personal injury or property damage.
VI. Medical Information and Consent:
I certify that I am in good health and have no medical conditions that would prevent my participation in the North Carolina Charity Fun Run. In the event of a medical emergency, I consent to emergency medical treatment as deemed necessary by medical personnel.
VII. Signature and Date:
Participant’s Signature:
Date: 11/30/2067
Parent/Guardian Signature (if the participant is under 18):
Date: 11/30/2067
