212° Waiver & Consent Form

 

 

________________________, understand that a minimal level of fitness is necessary to engage in this activity.  I further recognize that participation in this activity can expose me and my group to risks and hazards that are directly or inherently involved and could result in injury or development of a physical condition that may be serious in nature, including the potential loss of limb or life.  With full knowledge of the facts and circumstances surrounding this activity.  I voluntarily undertake in this participation, including all risk of loss of limb or life, property damage, injury to others, and hazards to me and my group.

 

I assure the Hempfield Area School District, Slippery Rock University, Butler Area School District, Butler YMCA, St Fidelis Church, Butler Catholic School, Slippery Rock School District and Butler Community College, that there are no health-related reasons or problems that preclude or restrict my participation in this activity.  I have adequate health insurance necessary to provide for and pay any medical costs that may directly or indirectly result from my participation in this activity and that I will indemnify and hold the Hempfield School District, Slippery Rock University, Butler School District, Butler YMCA, St. Fidelis Church, Butler Catholic School, Slippery Rock School District and Butler Community College or the 212° AAU ORGANIZATION harmless in this regard.  

 

I execute this document on my behalf and my group (listed below) with full knowledge of the contents and the consequences stated in this release and waiver.

 

DATE: ____________________________

 

Participants 18 years of age or less must have parent’s signature.

 

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13. __________________________________________         ________         __________________________________________

 

 

14. __________________________________________         ________         __________________________________________