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Bear Lake Monster Plunge, January 22, 2022 

This Waiver and Release is for participation in a Utah Division of State Parks and Recreation event or program or independent program occurring in or about a Utah State Park. 

Injury may result from your participation in this event/program. Additionally, property damage or loss may occur. You are expected to familiarize yourself with the rules of conduct for the event/program as well as Utah Division of State Parks and Recreation Policies. You are expected to follow proper operating procedures including safety procedures, plus any directions given by an authorized park or event/program coordinator employee. 

The undersigned, being at least eighteen years of age, and in consideration of participation in a State Park event/program or independent program occurring in or about a Utah State Park (hereinafter "event/program"), does hereby agree to this waiver and release. 

I do hereby agree to assume all risk which may be associated with or may result from, my participation in this event/program, including but not limited to the actual course of activities or while using the facility, parking lots, transportation or access to State Park's facilities and recreation sites. I acknowledge that this particular program, while conducted on State Park land or facilities, is not under the supervision, regulation or control of Utah Division of State Parks and cannot rely on the Utah Division of State Parks and Recreation to exercise supervision, regulation or control of the program. 

I recognize that participation in the event/program may involve moderate to strenuous physical activity and may cause physical and or emotional distress to participants. There may also be associated health risks. I state that I am free from any known heart, respiratory or other health problems that could prevent me from safely participating in any of the activities. 

I certify that I have medical insurance or otherwise agree to personally responsible for costs of any emergency or other medical care that I receive. I agree to release the State of Utah, Utah Division of State Parks and Recreation and its agencies, departments, officers, employees, agents and all sponsors, officials and staff or volunteers from the cost of any medical care that I receive as a result of participation in the event/program. 

I further agree to release the State of Utah, Utah Division of State of Parks and Recreation and its agencies, departments, officers, employees, agents, and all sponsors, officials and staff or volunteers from any and all liability, claims, demands, breach of warranty, negligence, actions, and causes of actions whatsoever for any loss, claim, damage, injury, illness, attorney's fees or harm of any kind or nature to me arising out of my participation in the event/program. This release extends to any claim made by my family, estate, heirs, or assigns arising from any way connected with aforementioned activities. 

CONSENT 

Consent is expressly given, in the event of injury, for any emergency aid, anesthesia and / or operation, if in the opinion of the attending physician, such treatment is necessary. 

 

I have carefully read and understand the contents of the foregoing language and I specifically intend it to cover my participation in the above stated event/program. 

 

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail for next year's event.
A signed copy of this waiver will be sent to the email address you provide.
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.

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*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information (Group Identification)

Group Name (please use the same name for all group members when possible)
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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