Pikeville Medical Center Run with the Cops 5K
Saturday, June 2, 2018 – 8 a.m.WAIVER AND RELEASE OF LIABILITY ANDAUTHORIZATION AND RELEASE TO USE LIKENESSPLEASE READ CAREFULLY BEFORE SIGNING Adult: 18 Years or Older – Minor: Under 18 Years of Age at Date of Event Event: Pikeville Medical Center Run with the Cops 5K/10K/1 Mile WalkLIABILITY RELEASE, INDEMNITY AND PROMISE NOT TO SUE: I, the undersigned below, understand I, my child or ward must register and run under his or her correct name, sex, and age division to avoid disqualification. I understand in consideration of my and/or my child’s or ward’s participation in the above referenced event, and any related activities (“Event”), wherever the/these Event(s) may occur, I acknowledge that I am aware that my or my child’s or ward’s participation in the Event has risks, which among other things, include but are not limited to falls, contact with other participants, the effects of weather, including high heat and/or humidity, traffic, conditions of the road and/or sidewalks, scrapes, bruises, twisted ankles, and various injuries to the body, including death and heat and stress related issues, and I freely assume on my own and/or my child’s or ward’s behalf all risks incidental to such participation. In consideration of my and/or my child’s or ward’s participation in the Event and on my own and/or my child’s or ward’s behalf, and on behalf of my and/or my child’s or ward’s heirs, executors, administrators and next of kin, I hereby release, covenant not to sue, and forever discharge the Released Parties (as defined below) of and from all liabilities, claims, actions, damages, costs and expenses of any nature arising out of, related to, or in any way connected with my or my child’s or ward’s participation in the Event and/or any such related and associated activities, and further agree to indemnify, defend, and hold each of the Released Parties harmless from and against any and all such liabilities, claims, actions, damages, costs and expenses including by way of example, but not limited to, all attorneys’ fees, costs of court, and the costs and expenses of other professionals and disbursements up through and including any appeal. I, for myself and my child and/or ward, understand that this Release and indemnity includes any claims based on the negligence and any action or inaction of any of the Released Parties and covers bodily injury (including, without limitation, death), property damage, and loss by theft or otherwise, whether suffered by me or my child or ward either before, during, or after such participation, including traveling to and from the Event. I declare that I and (if participating) my child or ward are physically fit and have the skill level required to participate in the Event and/or any such related and associated activities. I further authorize medical treatment for me and/or my child or ward, at my cost, if the need arises. However, if assistance or transport for medical treatment is denied by myself and/or my child or ward, I have full understanding that my conduct may increase my, and/or my child’s or ward’s risk of serious of serious injury or death, including other unknown risks not reasonably foreseeable at this time or the time of such denial, and I willingly agree to assume all risk and accept personal responsibility for the actions of myself and/or my child or ward and any damages as a result of such injury, including permanent disability or death. I agree to abide by any decision of a race official relative to any aspect of my, my child’s and/or ward’s participation in the Event, including the right of any official to deny or suspend my, my child’s and/or ward’s participation for any reason whatsoever. I understand that bicycles, skateboards, roller skates or roller blades, and animals are not allowed in the race and I, my child and/or ward will abide by this guideline. Baby joggers and headsets are strongly discouraged due to safety issues.For the purposes hereof, the “Released Parties” are: Organizers of the Event, Tri-Stateracer.com, and Pikeville Medical Center, Inc., and its affiliated organizations and sponsors, employees and associated personnel, officers, directors, volunteers, agents, including the owners and lessors of premises used to conduct the Event. AUTHORIZATION AND RELEASE TO USE LIKENESS: I further grant the Released Parties the right to photograph and/or videotape me and/or my child or ward and further to display, use, and/or otherwise exploit my and/or my child’s or ward’s name, face, likeness, voice, and appearance forever and throughout the world, in all media, whether now known or hereafter devised (including, without limitation, in online web casts, television, motion pictures, films, newspapers, and magazines) and in all forms including, without limitation, digitized images, whether for advertising, publicity, or promotional purposes, including, without limitation, publication of Event results and standings, without compensation, reservation, or limitation. This Waiver and Release of Liability and Authorization and Release to Use Likeness Form shall be governed by the laws of the Commonwealth of Kentucky without regard to that state’s choice of law principles, and any legal action related to or arising out of this Form shall be commenced exclusively in Pike County, Kentucky. I certify I am eighteen (18) years of age or older and, if I am executing this Waiver and Permission Form on behalf of my child or ward, the information set forth above pertaining to my child or ward is true and complete. SEVERABILITY. If any provision of this Form shall be unlawful, void, or for any reason unenforceable, then that provision shall be deemed severable from this Form and shall not affect the validity and enforceability of any remaining provisions. I HAVE READ, UNDERSTOOD AND ACCEPT THE CONDITIONS OF THIS WAIVER AND RELEASE OF LIABILITY AND AUTHORIZATION AND RELEASE TO USE LIKENESS. Participant Name: _____________________________________________________________________________ Signature: _____________________________________________________________ Date: _________________ Date of Birth: ______________________ Emergency Contact Number: _________________________________ Parent or Court Appointed Guardian (If Participant is under 18 years of age)_____________________________________________________________________________________________ Signature: _____________________________________________________________ Date: _________________ Street Address: ___________________________________________ City: _______________________________ State: __________ Zip Code: _____________ E-mail: _______________________________________________
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By clicking the Accept Waiver button below, I agree that I have read and accept the above waiver. I also agree that I am over 18 years of age OR the parent/legal guardian of a minor under 18 years of age OR the legal guardian of an incapacitated and/or mentally challenged person.
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