PRE-REGISTRATION

WAIVER AND RELEASE OF LIABILITY

IN CONSIDERATION OF the risk of injury that exists while participating in CHARITY
RIDE FOR THE TRANSPLANT HOUSE OF WEST MICHIGAN (hereinafter the
"Activity"); and
IN CONSIDERATION OF my desire to participate in said Activity and being given the right
to participate in same;
I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal
representatives (hereinafter collectively, "Releasor," "I" or "me", which terms shall also
include Releasor's parents or guardian if Releasor is under 18 years of age), knowingly and
voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any
and all rights, claims or causes of action of any kind arising out of my participation in the
Activity; and
I HEREBY release and forever discharge TRANSPLANT HOUSE OF WEST MICHIGAN,
located at 2051 W Toledo St, Fremont, Indiana 46737, their affiliates, managers, members,
agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns
(collectively "Releasees"), from any physical or psychological injury that I may suffer as a
direct result of my participation in the aforementioned Activity.
I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY
AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I
AM AWARE OF THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS
ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO: PHYSICAL OR
PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT,
TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS),
ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE
INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS'
NEGLIGENCE, CONDITIONS RELATED TO TRAVEL TO AND FROM THE
ACTIVITY, OR FROM CONDITIONS AT THE ACTIVITY LOCATION(S).
NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND
UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY.
I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and
all claims, suits or actions of any kind whatsoever for liability, damages, compensation or
otherwise brought by me or anyone on my behalf, including attorney's fees and any related
costs.
I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions,
acts or failures to act of any party or entity conducting a specific event or activity on behalf of
Releasees. In the event that I should require medical care or treatment, I authorize Transplant
House of West Michigan to provide all emergency medical care deemed necessary, including
but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing
of medical information with medical personnel. I further agree to assume all costs involved
and agree to be financially responsible for any costs incurred as a result of such treatment. I
am aware and understand that I should carry my own health insurance.
I FURTHER ACKNOWLEDGE that this Activity may involve a test of a person's physical
and mental limits and may carry with it the potential for death, serious injury, and property
loss. I agree not to participate in the Activity unless I am medically able and properly trained,
and I agree to abide by the decision of the Transplant House of West Michigan official or
agent, regarding my approval to participate in the Activity.
I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER
AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF
LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE Transplant
House of West Michigan AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS,
AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES,
PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS
OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE
ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST
Transplant House of West Michigan FOR PERSONAL INJURY OR PROPERTY
DAMAGE.
To the extent that statute or case law does not prohibit releases for ordinary negligence, this
release is also for such negligence on the part of Transplant House of West Michigan, its
agents, and employees.
I agree that this Release shall be governed for all purposes by Indiana law, without regard to
any conflict of law principles. This Release supersedes any and all previous oral or written
promises or other agreements.
In the event that any damage to equipment or facilities occurs as a result of my or my family's
or my agent's willful actions, neglect or recklessness, I acknowledge and agree to be held
liable for any and all costs associated with any such actions of neglect or recklessness.
THIS WAIVER AND RELEASE OF LIABILITY SHALL REMAIN IN EFFECT FOR THE
DURATION OF MY PARTICIPATION IN THE ACTIVITY, DURING THIS INITIAL AND
ALL SUBSEQUENT EVENTS OF PARTICIPATION.
THIS AGREEMENT was entered into at arm's-length, without duress or coercion, and is to
be interpreted as an agreement between two parties of equal bargaining strength. Both
Participant, _________________________ and Transplant House of West Michigan agree that
this agreement is clear and unambiguous as to its terms, and that no other evidence shall be
used or admitted to alter or explain the terms of this agreement, but that it will be interpreted
based on the language in accordance with the purposes for which it is entered into.
In the event that any provision contained within this Release of Liability shall be deemed to be
severable or invalid, or if any term, condition, phrase or portion of this agreement shall be
determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall
remain in full force and effect. If a court should find that any provision of this agreement to be
invalid or unenforceable, but that by limiting said provision it would become valid and
enforceable, then said provision shall be deemed to be written, construed and enforced as so
limited.
In the event of an emergency, please contact the following person(s) in the order presented:
Emergency Contact Contact Relationship Contact Telephone
I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18
YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I
CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND
ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I
AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND
THAT I AM SIGNING IT OF MY OWN FREE WILL.
Participant's Name:
Participant's Address:
Signature:
Date:
PARENT / GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release
must be signed by a parent or guardian, as follows:
I HEREBY CERTIFY that I am the parent or guardian of ____________________________,
named above, and do hereby give my consent without reservation to the foregoing on behalf of
this individual.
Parent / Guardian Name:
Relationship to Minor:
Signature:
Date:

 

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