Synergy Fields Release/liability And Athlete Info Form printable pdf download

Synergy Fields

Release/Liability and Athlete info Form

In recognition of and with knowledge of the fact that engaging in any form of physical activity involves a substantial risk of personal

injury, I, the undersigned, warrant that _____________________________________ is presently in good physical condition and

hereby agree to assume the risk of an injury that may result from the participation of activities at Synergy Fields.

Therefore, in consideration for being permitted to participate in such an event, I hereby release, waive and forever discharge Synergy

Fields, their agents, employees and officers, from any and every claim, demand or act of whatever kind, arising from any bodily harm,

personal injury or death resulting from any accident which may occur as a result of participation in such an event. Further, and to the

same extent and scope, I release said parties from any claim whatsoever which may be attributable to the receipt of first aid or other

emergency treatment rendered me in connection with my participation in such an event.

I, the undersigned, affirmatively swear that I am the parent or legal guardian of the participant and am fully competent to and do

hereby execute this release and waiver on behalf of that individual, heirs or assigns. I further represent and warrant that I have read

and fully understand the terms of this document and their legal significance.

In witness whereof I have voluntarily and without inducement from any party executed this release and waiver. I grant Synergy Fields

the irrevocable right and permission, throughout the world, in connection with the photographs that were taken and provided to

Synergy Fields: the right to use and reuse, in any manner at all, said photographs or video, modified or altered, either by themselves or

in conjunction, in any medium or form of distribution, for any purposes whatsoever without limitation, all promotional and advertising

uses or other trade purposes, in connection with my name. I release all claims and actions arising with my connection to Synergy

Fields without any violations to my privacy or libel. This release shall inure to the benefit of the assigns, licensees and legal

representatives, and owners of Synergy Fields.

Athlete Name:___________________________________________________________

Age:____________________________________________________________________

Email:__________________________________________________________________

Address____________________________City_____________St______Zip_________

Phone:__________________________________________________________________

School _________________________________________________________________

Sport

__________________________D.O.B____________________________________

_________________________________________________

Parent Signature if under 18

Synergy Fields Release/liability And Athlete Info Form