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Release of Liability Waiver 

337 Cassville Rd. 

Cartersville, GA 30120

PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK 

In consideration of the services of Pettit Creek Farms their agents, owners, officers, volunteers, employees, and all other persons or entities
acting in any capacity on their behalf (hereinafter collectively referred to as "PCF"), I hereby agree to release, indemnify, and discharge
PCF, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows: 

1. I acknowledge that my participation in bungee quad and zip line activities entails known and unanticipated risks that could result in
physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply
cannot be eliminated without jeopardizing the essential qualities of the activity.
The risks include, among other things: slips and falls; falls from equipment; rope burns; pinches, scrapes, twists and jolts that could result
in scratches, bruises, sprains, lacerations, fractures, concussions, or even more severe life threatening injuries; the use of ropes, harnesses,
and other equipment; being struck by other objects dislodged or thrown from above; loose and/or damaged artificial holds; equipment
failure; the negligence of others, visitors, participants, or other persons who may be present; transmissible pathogen or disease; the forces
of nature, including lightning and rapid weather changes; the risk of falling from significant heights; exposure to temperature and weather
extremes which could cause hypothermia, hyperthermia (heat related illnesses), heat exhaustion, sunburn, dehydration; exposure to
potentially dangerous wild animals, insect bites, and hazardous plant life; my own physical condition, and the physical exertion associated
with this activity; traveling to and from activity locations raises the possibility of any manner of transportation accidents.
Furthermore, PCF personnel have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a
participant's fitness or abilities. They might misjudge the weather or other environmental conditions. They may give incomplete warnings
or instructions, and the equipment being used might malfunction. 

2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely
voluntary, and I elect to participate in spite of the risks. I agree to wear a properly fitted and secured helmet while participating in this
activity.

3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless PCF from any and all claims, demands, or
causes of action, which are in any way connected with my participation in this activity or my use of PCF's equipment or facilities, including
any such claims which allege negligent acts or omissions of PCF.

4. Should PCF or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to
indemnify and hold them harmless for all such fees and costs.

5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear
the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may
have.

6. In the event that I file a lawsuit against PCF, I agree to do so solely in the state of Georgia; and I further agree that the substantive law
of that state shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is
found to be void or unenforceable, the remaining document shall remain in full force and effect. 

 

 

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I
may be found by a court of law to have waived my right to maintain a lawsuit against PCF on the basis of any claim from which I
have released them herein. I also agree that this document is valid for subsequent visits and participation at PCF. I have had
sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms. 

In consideration of the minor(s) being permitted by PCF to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless
PCF from any and all claims which are brought by, or on behalf of minor(s), and which are in any way connected with such use or
participation by minor(s). 

 

                        July 29, 2021

 

 

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
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*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are 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 Information
1. Are you allergic to any kind of bee sting or insect?*
No
Yes, Make sure you have your Epi Pen, if needed.
2. Are you a diabetic?*
No
Yes
3. Do you have any of the following? Check all that apply.
Seizures
Asthma
Cardiac history
4. Have you had any surgeries in the last 6 months?*
No
Yes

List any Surgeries from the past 6 months here
5. Are there any medical conditions that we may need to know about?*
No
Yes

List any other medical conditions that we need to know about here
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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