SAFETY WAIVER | 40+Double Dutch Club

40+ DOUBLE DUTCH CLUB
OFFICIAL MEMBER*
Release and Hold Harmless
Agreement/Waiver of Liability Form

Participant First Name

Participant Email

Participant Last Name

Birthday

Phone

SubClub Location

Today's Date

Emergency Contact

Emergency Contact Name & Relationship

I declare that the info I’ve provided is accurate & complete

I, the undersigned participant, request voluntary participation for myself to participate in 40+ Double Dutch Club activities. I consent to participation and acknowledge that I fully understand that my participation may involve risk of serious injury, including losses which may result not only from my own action, inactions or negligence, but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment or areas where the activity is being conducted, and/or the rules of play of this type of event or activity. I understand that if I have any risk concerns, I should discuss the risks associated with my participation with the activity coordinators before I sign this document and before the activity begins. I certify that I am in good health and have no physical condition that would prevent participation in this activity. Furthermore, I agree to use my personal medical insurance as a primary coverage payment if accident or injury occurs. I consent to emergency medical treatment in the event such care is required. To comply with public health best practices during the COVID-19 outbreak and aftermath, we respectfully ask that by signing below, you acknowledge and agree that you are fully aware of the symptoms of COVID-19 and confirm that you are not experiencing any symptoms, nor do you have reason to suspect that you have been exposed to COVID-19 within the past 14 days. Additionally, you fully understand that 40+ DDC cannot guarantee that its events and/or participants are free of the COVID-19 virus. I also agree that photographs, pictures, slides, movies, video or other media coverage of me may be taken in connection with my participation in the activity without compensation from 40+ Double Dutch Club and consent to use of photographs, pictures, slides, videos or other media/ social media coverage for any legal purpose. Knowing and understanding the risks involved with participation in the activity, I hereby voluntarily and willingly assume responsibility for all the risks and dangers associated with my participation in the activity. I agree I am financially responsible for any losses resulting from my actions and will indemnify the 40+ Double Dutch Club for any loss or damage caused by myself during this activity. I have read this release and hold harmless agreement and understand the terms used in it and their legal significance. This waiver and release is freely and voluntarily given with the understanding that the right to legal recourse against the 40+ Double Dutch Club is knowingly given up in return for allowing my participation in the activity. My signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators and assigns. This agreement remains in effect as long as I participate in any 40+ Double Dutch Club activities.

Your Signature

THANK YOU!

40+ DOUBLE DUTCH CLUB OFFICIAL MEMBER* Release and Hold Harmless Agreement/Waiver of Liability Form

40+ DOUBLE DUTCH CLUB
OFFICIAL MEMBER*
Release and Hold Harmless
Agreement/Waiver of Liability Form