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Wheelhopper Mountain Bike Hash House Harriers
of Atlanta GA USA
http://www.wheelhopper.com/

Agreement Release and Waiver of Liability Form


Name:____________________________________________________________________________

HashName:________________________________________________________________________

Address:__________________________________________________________________________

City:____________________________________________ State:___________ Zip:_____________

Phone:(_________)__________-_______________   home[   ]    office[   ]

Email:____________________________________________________________________________

Sex (please circle):   M     F

Birthdate: ______/______/______   Age on 1/1/2002:___________

EMERGENCY CONTACT:

Name:____________________________________________________________

Phone:(_________)__________-_______________   Relationship:_____________________

AGREEMENT RELEASE AND WAIVER OF LIABILITY

In consideration of being permitted to participate in or assisting others in participating in Wheelhopper Mountain Bike Hash House Harriers of Atlanta GA USA ("Wheelhopper Hash") events, and related events and activities, on behalf of myself, or a minor child or ward, heir, next of kin, personal representative, successor or assign;
(1) I ACKNOWLEDGE, UNDERSTAND AND DECLARE THAT:
  (a) To the best of my knowledge, I am in GOOD PHYSICAL CONDITION and have no disease or injury that would be aggravated by participating in activities related to the Wheelhopper Hash.
  (b) Participating or assisting others in participating in the Wheelhopper Hash events may involve RISK OF INJURY TO ME, INCLUDING DEATH, LOSS OR DAMAGE TO ME OR MY PROPERTY, or other consequences, which might result not only from my own actions, inactions or negligence but also the actions, inactions or negligence of others, the rules of play, or the conditions of the premises or of any equipment used.
  (c) I have taken and will take precautions to ensure 1) that all necessary EQUIPMENT are in adequate working condition, 2) that I have at my disposal all necessary APPAREL, ACCESSORIES, TOOLS, and SPARE PARTS, and 3) that I have prepared myself with and have at my disposal all necessary FLUIDS and ENERGY REPLACEMENT PRODUCTS/FOODS to enable me and my equipment to stand up to the expected and unexpected conditions that might be encountered during participation in any Wheelhopper Hash event.
  (d) There may be OTHER RISKS not known or not reasonably forseeable; and Understanding All of the Above.
(2) I ASSUME ALL OF THE ABOVE RISKS AND RELEASE, WAIVE, DISCHARGE, HOLD HARMLESS, INDEMNIFY AND COVENANT NOT TO SUE:
  (a) the Wheelhopper Hash, or any of its officers, committee members, representatives, event organizers, members, or any agents of or affiliated with Wheelhopper Hash;
  (b) any successor, organization, other participants, sponsors, or advertisers, their respective administrators, officers, directors, agents, representatives, employees, or volunteers of such entities or organizations;
  (c) owners, lessors and lessees of premises used by Wheelhopper Hash for any events;
FROM ANY AND ALL LIABILITY FOR INJURY, INCLUDING DEATH, LOSS OR DAMAGE TO PERSON OR PROPERTY, OR ANY OTHER CONSEQUENCE in connection with entry in or arising out of participation in, performance in or lack of performance in, including travel en route to and from, the Wheelhopper Hash events.
(3) I AGREE THAT:
  (a) Prior to participating as an athlete, I, or in the case of a minor, a parent or guardian, will INSPECT the facilities and equipment to be used, and if I believe same to be unsafe, I will immediately REPORT such condition(s) to the appropriate Wheelhopper Hash official and either DECLINE TO PARTICIPATE or ASSUME THE RISK of participating;
  (b) I will ALLOW my PHOTOGRAPH, PICTURE or LIKENESS and/or VOICE to APPEAR in any official documentary, promotional (including any and all advertisements), television, radio, film or Internet coverage of the Wheelhopper Hash events, WITHOUT COMPENSATION.
  (c) I MUST wear a HELMET on my head at all times while riding Wheelhopper Hash bicycle events.
(4) I CONSENT TO:
  ALL EMERGENCY MEDICAL TREATMENT as may be deemed appropriate under existing circumstances by medical personnel or personnel associated with Wheelhopper Hash.
I HAVE READ THIS FORM IN ITS ENTIRETY AND HAVE PROVIDED TRUTHFUL INFORMATION.


Name of Athlete/Participant (print):_____________________________________________________________

Signature:__________________________________________________ Date:__________________

Name of Parent/Legal Guardian (if athlete/participant is a minor)(print):_____________________________________

Signature:__________________________________________________ Date:__________________
(Signature of Parent/Legal Guardian, Individually and in the capacity as Parent/Legal Guardian if Athlete/participant is under 18 years of age)
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