Loading...

 PILGRIM PINES

ACTIVITIES WAIVER, PARENTAL PERMISSION AGREEMENT, RELEASE, INDEMINIFICATION OF ALL CLAIMS & COVENANT NOT TO SUE


NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. Read this document carefully and in entirety. By signing this agreement, you give up your right to bring a court action to recover compensation or obtain any other remedy for any personal injury or property damage however caused arising out of your participation in any activity related in any way to Pilgrim Pines Camp and Retreat Center, Camp Squanto, East Coast Conference of the Evangelical Covenant Church, Inc. (a CT corporation), and East Coast Conference of the Evangelical Covenant Church, Inc. (a NH corporation DBA Pilgrim Pines Conference Center) (collectively “Pilgrim Pines”), now or at any time in the future.

IN CONSIDERATION of my and/or my child[ren] being given the opportunity to participate in any activity related in any way to Pilgrim Pines Camp and Retreat Center, Camp Squanto, East Coast Conference of the Evangelical Covenant Church, Inc. (a CT corporation), and East Coast Conference of the Evangelical Covenant Church, Inc. (a NH corporation DBA Pilgrim Pines Conference Center) (collectively “Pilgrim Pines”), including, but not limited to, indoor and/or outdoor games, swimming, vehicular transportation, boating, frisbee, drama, ropes courses, zip lines, climbing walls, ball games, camp fires, walking, running, hiking, jumping, climbing, archery, shooting range, baseball, basketball, soccer, volleyball, other sports, fishing, golfing, bounce house, carpentry, dance, knitting, painting, rocket building or any other activity connected in any way with Pilgrim Pines (hereinafter "Activities") I, for my child and for myself and his/her parents, personal representatives, assigns, heirs, and next of kin (“Releasors”) state and agree as follows:

I UNDERSTAND, ACKNOWLEDGE, AND HAVE BEEN FULLY INFORMED (a) that the Activities involve the risk of minor and/or serious injury including permanent disability, paralysis, disease, infection, illness including exposure to and infection with viruses or bacteria, and death, and/or property damage (the “Risks”); (b) these Risks and dangers may be caused by my child’s own actions, or inactions, the actions or inactions of others participating in the Activities, the conditions in which the Activities take place, or the negligence of the Releasees named below; and, (c) there may be other risks and social and economic losses either not known to me or not readily foreseeable at this time that may result as a direct or indirect result of the Activities; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I and/or my child[ren] may incur directly or indirectly as a result of my and/or the child[ren’s] participation in the Activities. The undersigned also expressly acknowledges that injuries received may be compounded or increased by negligent rescue operations or procedures of the Releasees.

Coronavirus / COVID-19 Warning & Disclaimer

Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a mean to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in Pilgrim Pines programs and activities or accessing Pilgrim Pines facilities could increase the risk of contracting COVID-19. Pilgrim Pines in no way warrants that COVID-19 infection will not occur through participation in Pilgrim Pines programs or activities or accessing Pilgrim Pines facilities.


I HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE (a) Pilgrim Pines, East Coast Conference of the Evangelical Covenant Church, Inc. (a CT corporation), and East Coast Conference of the Evangelical Covenant Church, Inc. (a NH corporation DBA Pilgrim Pines Conference Center) and/or its staff, members, trustees, administrators, directors, employees, workers, volunteers, agents, officers, counselors, instructors, rescue personnel, (b) the owners and lessees of premises used to conduct the Activities, (c) the owners and lessees of equipment used in the Activities, or (d) other participants, campers, or persons involved in the Activities, all of whom for the purposes herein are referenced to as "Releasees," from all liability to me and/or the child[ren] named below, to the child[ren]’s parents or next of kin, personal representatives, assigns, heirs, for any and all loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in the death to my person or of the child[ren] arising out of or related directly or indirectly to the Activities, whether caused by the negligence of the Releasees or otherwise, including negligent rescue operations.      

I FURTHER AGREE that if, despite this release and waiver of liability, assumption of risk, and indemnity agreement, I, or anyone on my or the child[ren]’s behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS each of the Releasees from any litigation expenses, attorney fees, loss, liability, damage, or cost which may incur as a result of such claim, whether the claim is alleged to have been caused by the negligence of the Releasees or otherwise. Further, any claims or disputes relating to the child’s participating in the Activities shall be venued in the Cheshire County Superior Court in the State of New Hampshire, and that New Hampshire law shall govern this agreement.

I HEREBY STATE and represent that I am qualified, in good health, in proper physical condition, and of reasonable age and maturity to participate in such Activities.

I HEREBY GRANT PERMISSION for the child[ren] to participate in the Activities, and represent that each child is qualified, in good health, in proper physical condition, and of reasonable age and maturity to participate in such Activities.

I HEREBY GRANT PERMISSION for a licensed physician or other person, chosen by the leadership of Pilgrim Pines, to provide any medical emergency treatment necessary to me and/or my child[ren]. I will assume the liability for any resulting costs not covered by my health insurance.  

I HEREBY AGREE that I am, for myself, and as the undersigned parent or legal guardian of the child or children identified below, am and will be fully responsible to pay for any damage to the real or personal property of Pilgrim Pines or to any other person participating in or related to the Activities, which damage is caused by the negligent or intentional acts of myself and/or my child[ren].

PERMISSION TO USE MY PHOTOGRAPH OR IMAGE OR PHOTOGRAPH OF CHILD. I hereby grant Pilgrim Pines permission to use, reproduce, publish or distribute any photographs, films, videotapes and/or sound recordings of me and/or my child[ren] for use in materials, publications, or other documents, including but not limited to a website available to the world wide web, it or they may create, without compensation to me or my child[ren].

I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY AND AN ASSUMPTION OF THE DUTY TO INDEMNIFY TO THE GREATEST EXTENT ALLOWED BY LAW. I UNDERSTAND THAT I HAVE THE RIGHT TO CONSULT WITH AN ATTORNEY PRIOR TO SIGNING BELOW REGARDING THE LEGAL IMPLICATIONS OF THIS WAIVER.

I further certify that I am of lawful age and otherwise legally competent to sign this document. I further understand that the terms of this agreement are legally binding and certify that I am signing this agreement, after having carefully read it, of my own free will.

Today's Date: November 21, 2024

First Guest's Name

First Name*

Last Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

Email*

Confirm Email*
Group Information
What is the name of the group you are attending with?*
Dietary Restriction Requests (# of people with restrictions that are included in this agreement):
Gluten Free
Dairy Free
Vegetarian
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*

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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!