Dpr Accident Waiver And Release Of Liability Form

DPR

DC DEPARTMENT OF PARKS AND RECREATION

DISTRICT   O F   C OLUMBIA   D EPARTMENT   O F   P ARKS   A ND   R ECREATION   ( “DPR”)  

ACCIDENT   W AIVER   A ND   R ELEASE   O F   L IABILITY   F ORM  

 

Name   o f   A ctivity,   E vent,   o r   P rogram   ( hereinafter,   t he   “ Activity”):______________________________________  

 

Date(s)   o f   A ctivity:____________________________________________________________________________  

 

Location   o f   A ctivity:___________________________________________________________________________  

 

I  HEREBY  ASSUME  ALL  OF  THE  RISKS  OF  PARTICIPATING  IN  THIS  ACTIVITY,  including,  but  not  limited  to,  any  

risks  that  may  arise  from  the  condition  of  the  equipment  and/or  real  and  personal  property  owned,  managed,  

maintained,   a nd/or   c ontrolled   b y   t he   D istrict   a t   t he   l ocation   o f   t he   A ctivity.  

 

I   r ecognize   t hat   p articipation   i n   t he   A ctivity   c an   c arry   w ith   i t   p otential   r isks,   i ncluding,   b ut   n ot   l imited   t o,   b odily  

injury.     I   certify   that   I   have   not   been   advised   to   refrain   from   participating   in   the   Activity   by   a   medical  

professional.     T here   a re   n o   h ealth-­‐related   r easons   o r   p roblems   t hat   p reclude   m y   p articipation   i n   t his   A ctivity.      

 

I  hereby  consent  to  receive  medical  treatment  that  may  be  deemed  advisable  in  the  event  of  injury,  accident  

and/or  illness  during  this  Activity.    However,  this  consent  does  not  require  DPR  to  initiate  medical  care  on  my  

behalf.    I  agree  to  accept  full  responsibility  for  and  to  pay  for  the  cost  of  medical  care,  transportation  and  any  

other   i ncidental   e xpenses   a rising   f rom   a ny   s uch   e vent.  

 

In   consideration   of   receiving   permission   to   participate   in   this   Activity,   I   hereby   take   action   for   myself,   my  

executors,   a dministrators,   h eirs,   n ext   o f   k in,   s uccessors   a nd   a ssigns   a s   f ollows:    

 

(A)   I   WAIVE,   RELEASE   AND   DISCHARGE   the   District   of   Columbia   and   its   agencies,   agents,   employees,  

volunteers,  contractors,  sponsors,  advertisers,  partners,  and/or  representatives  (each  a  “District  Party”  

and   collectively   the   “District   Parties”)   from   any   and   all   liabilities,   claims,   penalties,   suits,   demands,  

judgments,   costs,   interest,   and   expenses   (including,   attorneys’   fees   and   costs)   (each   a   “Loss”   and  

collectively  the  “Losses”)  including,  but  not  limited  to,  Losses  arising  from  or  connected  in  any  way  to  

my  death,  disability,  personal  injury,  property  damage,  property  theft  or  actions  of  any  kind  which  may  

hereafter   o ccur   t o   m e   i n   c onnection   w ith   t he   A ctivity   i ncluding   m y   t raveling   t o   a nd   f rom   t his   A ctivity;    

 

(B)  I  AGREE  TO  INDEMNIFY  and  HOLD  HARMLESS  the  District  Parties  for,  from,  and  against  any  and  all  

Losses   a rising   o r   r esulting   f rom   p articipation   i n   t his   A ctivity;    

 

I   c ertify   t hat   I   h ave   r ead   t his   d ocument,   t hat   I   a m   a t   l east   1 8   y ears   o ld   a nd   c an   s ign   t his   W aiver,   a nd   t hat   I   f ully  

understand  its  content.    I  am  aware  that  this  is  a  release  of  liability  and  is  a  contract  made  in  consideration  of  

my   p articipation   i n   t he   A ctivity.    

 

 

______________________________     _____________________________    

_________________    

Participant’s   N ame   ( Print)    

 

Participant’s   S ignature      

 

Date  

 

 

___________________________________________________________________________________________  

Participant’s   P hone   #   a nd   A ddress  

 

 

_______________________________________________  

Emergency   C ontact   N ame   a nd   P hone   #