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Expires 12/31/2024

RELEASE OF LIABILITY AND ASSUMPTION OF RISK


The individual named below (referred to as “I” or “me”) desires to ride motorcycles and/or other motorized vehicles, from time to time, on property commonly known as, W 1000 N, Wawaka, IN 46794 (the “Activity”), and owned by Riders Motorcycle Club, an Indiana nonprofit corporation, located at P.O. Box 297, Goshen, IN 46527 (the “Company”). In consideration of being permitted by the Company to participate in the Activity and in recognition of the Company’s reliance hereon, I agree to the terms and conditions set forth in this instrument (this “Release”).

I AM AWARE AND UNDERSTAND THAT THE ACTIVITY IS A POTENTIALLY DANGEROUS ACTIVITY AND INVOLVES THE RISK OF SERIOUS INJURY, DISABILITY, DEATH, AND OR PROPERTY DAMAGE. I ACKNOWLEDGE THAT ANY INJURIES THAT I SUSTAIN MAY RESULT FROM OR BE COMPOUNDED BY THE ACTIONS, OMISSIONS, OR NEGLIGENCE OF THE COMPANY, INCLUDING NEGLIGENT EMERGENCY RESPONSE OR RESCUE OPERATIONS OF THE COMPANY. NOTWITHSTANDING THE RISK, I ACKNOWLEDGE THAT I AM VOLUNTARILY PARTICIPATING IN THE ACTIVITY WITH KNOWLEDGE OF THE DANGER INVOLVED AND HEREBY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF INJURY, DISABILITY, DEATH, AND/OR PROPERTY DAMAGE ARISING FROM MY PARTICIPATION IN THE ACTIVITY, WHETHER CAUSED BY THE ORDINARY NEGLIGENCE OF THE COMPANY OR OTHERWISE.

I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, expressly waive and release any and all claims, now known or hereafter known, against the Company, and its officers, directors, managers, employees, agents, affiliates, successors, and assigns (collectively, “Releasees”), on account of injury, disability, death, or property damage arising out of or attributable to my participation in the Activity, whether arising out of the ordinary negligence of the Company or any Releasees or otherwise. I covenant not to make or bring any such claim against the Company or any other Releasee, and forever release and discharge the Company and all other Releasees from liability under such claims. This waiver and release does not extend to claims for gross negligence, willful misconduct, or any other liabilities that Indiana law does not permit to be released by agreement.

I shall defend, indemnify, and hold harmless the Company and all other Releasees against any and all losses, damages, liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties, fines, costs, or expenses of whatever kind, including reasonable attorney fees, fees, the costs of enforcing any right to indemnification under this Release, and the cost of pursuing any insurance providers, incurred by/awarded against the Company or any other Releasees in a final non-appealable judgment, arising out of or resulting from any claim of a third party related to my participation in the Activity, including any claim related to my own negligence or the ordinary negligence of the Company.

I hereby consent to receive medical treatment deemed necessary if I am injured or require medical attention during my participation in the Activity. I understand and agree that I am solely responsible for all costs related to such medical treatment and any related medical transportation and/or evacuation. I hereby release, forever discharge, and hold harmless the Company from any claim based on such treatment or other medical services.

This Release constitutes the sole and entire agreement of the Company and me with respect to the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, with respect to such subject matter. If any term or provision of this Release is invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other term or provision of this Release or invalidate or render unenforceable such term or provision in any other jurisdiction. This Release is binding on and shall inure to the benefit of the Company and me and their respective successors and assigns. All matters arising out of or relating to this Release shall be governed by and construed in accordance with the internal laws of the State of Indiana without giving effect to any choice of law provision or rule (whether of the State of Indiana or any other jurisdiction). Any claim or cause of action arising under this Release may be brought only in the federal and state courts located in Noble County, Indiana and I hereby consent to the exclusive jurisdiction of such courts.

BY SIGNING, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS RELEASE AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE COMPANY.

THIS AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT MUST BE COMPLETED BEFORE PARTICIPANT CAN PARTICIPATE IN ACTIVITIES. TREATMENT FOR INJURY WILL BE BASED ON INFORMATION PROVIDED HEREIN.

Today's date: December 21, 2024 


Guardian's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
First Guardian's Name

First Name*

Last Name*

Phone*
First Guardian's Date of Birth*
First Guardian's Signature*
Second Guardian's Name

First Name*

Last Name*
Second Guardian's Date of Birth*
Third Guardian's Name

First Name*

Last Name*
Third Guardian's Date of Birth*
Fourth Guardian's Name

First Name*

Last Name*
Fourth Guardian's Date of Birth*
Fifth Guardian's Name

First Name*

Last Name*
Fifth Guardian's Date of Birth*
Sixth Guardian's Name

First Name*

Last Name*
Sixth Guardian's Date of Birth*
Seventh Guardian's Name

First Name*

Last Name*
Seventh Guardian's Date of Birth*
Eighth Guardian's Name

First Name*

Last Name*
Eighth Guardian's Date of Birth*
Ninth Guardian's Name

First Name*

Last Name*
Ninth Guardian's Date of Birth*
Tenth Guardian's Name

First Name*

Last Name*
Tenth Guardian's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Insurance Card
  
Note: Attach a copy of your insurance card, front and back, to expedite medical treatment.
Valid file types: JPG, GIF, PNG, and PDF
Additional Emergency Information

Other medical information


List Allergies

Medical Conditions

List Medications

In an emergency when parent/legal guardian cannot be reached or is not applicable, please contact the following: 


Name:

Home Phone:

Cell Phone:

Parent/Guardian Waiver for Minors

I hereby certify that I am the parent or legal guardian of the minor named above. I have the legal right to consent to and, by signing below, I hereby do consent to the terms and conditions of this Release of Liability.



By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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