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AGREEMENT RELEASE AND WAIVER OF LIABILITY

In consideration of the opportunity to participate in Multnomah Athletic Club’s event, herein referred to as ‘‘the program’’ made available through the Multnomah Athletic Club, herein referred to as “MAC,” I agree as follows:

1. I understand and acknowledge that participation in the program may be dangerous and may involve risks which include, but are not limited to, bodily injury, partial or total disability, paralysis and death. I also understand and acknowledge that the social and economic losses or damages which can result from those risks and dangers can be severe and that not all such risks and dangers may be known or reasonably foreseeable at this time. I accept the responsibility for losses or damages resulting from all such risks and dangers involved in participation in the program.

2. I agree to take appropriate precautions for my own safety and that of others when participating in the program and further agree that, before participating I will inspect the facilities and equipment to be used and will, if I believe anything is unsafe, immediately advise the person in charge of that unsafe condition and will refuse to participate.

3. I hereby release, waive and discharge MAC, its coaches, instructors, officials and volunteers engaged by MAC, in the conduct of the program, and MAC officers, directors, agents and employees, from all liability to me and to my conservators, guardians or other legal representatives, assigns, heirs and next of kin for any and all claims, demands, losses or damages on account of any injury, death or damage to property, arising out of my participation in the program, arising from negligence, whether on MAC premises or elsewhere, including transportation of myself and/or my child/ ward to and from events and venues.

4. If competing in an offsite event/venue, I assume responsibility for transportation of myself and/or my child(ren)/ward(s) to and from those events and/or venues.

5. I also hereby agree to indemnify and to hold harmless from any claim or demand on account of injury or damage which I may suffer as a result of participation in the program MAC and all other persons mentioned in Paragraph 3.

6. I understand that this release, waiver and agreement to indemnify and hold harmless includes, but is not limited to, damages which are caused, or alleged to be caused, in whole or in part by the negligence of MAC and the individuals listed in Paragraph 3.

I have read the above agreement of release and waiver of liability and understand that by signing it I have given up substantial rights. I sign this agreement voluntarily.

If participant is not over 18 years of age:

I am the parent or legal guardian of the participant named above, who is under the age of 18 years, and who wishes to participate in Multnomah Athletic Club’s program described above in Paragraph 1. In consideration of Multnomah Athletic Club’s allowing my child or ward to participate in that program, I hereby agree to indemnify Multnomah Athletic Club and all other persons described in Paragraph 3 above, and to hold each and all of them harmless from any claim or demand on account of injury to or damage suffered by my child or ward as a result of participation in that program, whether on Multnomah Athletic Club premises or elsewhere.

I acknowledge it is my responsibility to deliver my child(ren) to the program and to pick up my child(ren) promptly upon the scheduled conclusion of the program. If competing in an offsite event/venue, I assume responsibility for transportation of myself and/or my child(ren)/ward(s) to and from those events and/or venues.

This agreement includes, but is not limited to, claims or demands on account of injury or damage caused or allegedly caused by the negligence of MAC or any of the individuals listed in Paragraph 3.

Today's Date: October 21, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Please enter in your membership number. If you are a guest please enter NA *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Please enter in your membership number. If you are a guest please enter NA *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Please enter in your membership number. If you are a guest please enter NA *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Please enter in your membership number. If you are a guest please enter NA *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Please enter in your membership number. If you are a guest please enter NA *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Please enter in your membership number. If you are a guest please enter NA *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

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Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Please enter in your membership number. If you are a guest please enter NA *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

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Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

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Participant'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:*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Primary Physician Information

Primary Physician Name *

Physician Phone number *
Event Information

Year/Season:

Class/Clinic/Event/Activity/Camp/Lesson:

Event Registration No:
I, the natural parent and/or guardian of a minor child, do hereby fully authorize Multnomah Athletic Club coaching staff or designated chaperones to act on my behalf in the event my child(ren) is the victim of an accident, injury or illness that requires immediate medical or surgical care. Actions on behalf of my child(ren) shall include but not be limited to authorization for Multnomah Athletic Club coaching staff or other chaperones to arrange for such medical care as they deem appropriate, substantiated by local medical advice, and to give any required consent for such medical care. I acknowledge that it is my responsibility to advise Multnomah Athletic Club, in writing, of any allergies, medical problems or prescription medicine requirements that would be pertinent in the treatment of my child(ren).
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Please enter in your membership number. If you are a guest please enter NA *
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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