Office Use Only Date Received

Office use only – Date received:______

DIXIE ROCK 19 ONLY ACKNOWLEDGEMENT, WAIVER, & RELEASE FROM LIABILITY

COMPLETE BOTH PORTIONS OF THIS FORM AND RETURN WITH YOUR ENTRY FEE. DO NOT CUT OFF ANY PORTION OF THIS FORM.

I acknowledge that a sport climbing competition is an extreme test of a person’s physical and mental limits and that sport climbing is an inherently dangerous activity with the potential for death, serious injury, and property loss. I understand that sport climbing carries with it the risk of broken bones, joint damage, and death. I understand that proper conditioning is essential to safely compete in this event. I understand that on the day or days of the competition it is essential that I properly stretch and use warm-up exercises prior to climbing, and further that I understand that the staff, sponsors, and volunteers of the event will not give instruction in the proper methods to stretch, warm-up, or climb. I HEREBY ASSUME THE RISKS OF PARTICIPATION IN THE “DIXIE ROCK 19” CLIMBING COMPETITION. I certify that I am physically fit, have the knowledge necessary to compete safely and have not been advised otherwise by a qualified medical person.

In return for allowing me to participate in the “DIXIE ROCK 19 CLIMBING COMPETITION”, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors and assigns as follows: a) WAIVE, RELEASE, DISCHARGE, AND AGREE NOT TO SUE, from any and all liability for my death, disability, personal injury, property damage, property theft or action of any kind which may hereafter accrue to me as a result of my participation in, or my traveling to the “DIXIE ROCK 19 CLIMBING COMPETITION”, THE FOLLOWING PERSONS OR ENTITIES: The Town of Chapel Hill, the Chapel Hill Parks and Recreation Commission, the Chapel Hill Parks and Recreation Department, the event sponsors, the event judges, the event volunteers, and the event participants; b) INDEMNIFY AND HOLD HARMLESS the persons or entities mentioned in this paragraph from any and all liabilities or claims made by other individuals or entities as a result of any of my actions during the “DIXIE ROCK 19 CLIMBING COMPETITION”.

I hereby consent to receive treatment in the event of my injury, accident, and/or illness during the “DIXIE ROCK 19 CLIMBING COMPETITION”.

I understand that at the “DIXIE ROCK 19 CLIMBING COMPETITION”, I may be photographed. I agree to allowing my photo, video, or film likeness to be used for any legitimate purpose by the “DIXIE ROCK 19 CLIMBING COMPETITION”, the event producer(s), event sponsor(s), and/or assigns.

I HEREBY CERTIFY THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER, I HAVE READ THIS DOCUMENT, AND, I UNDERSTAND ITS CONTENTS.

______Printed Name Date

______Signature

______Parent or guardian signature if participant is a Minor

______Relationship to Minor FORM – DR 19 1 0F 2 L WAIVER DIXIE ROCK 19 ONLY

FILL OUT BOTH PORTIONS IF PARTICIPANT IS A MINOR

PARENT/GUARDIAN WAIVER—FOR MINOR

If the applicant is under 18 years of age, the parents or guardian must execute, in addition to the standard waiver form on the other side, the following waiver and consent.

The undersigned ______(parent/guardian name) referred to as the parent and/or natural guardian or legal guardian for ______(minor’s name) does hereby represent that he/she is, in fact, acting in such capacity and agrees to save and hold harmless and indemnify each and all parties herein named on the front of the form as releases from all liability, loss, cost, claim or damage whatsoever that may be imposed upon said releases because of any defect in or lack of such capacity to so act and release said releases on behalf of both of the undersigned.

______Parent or guardian Date

______Relationship to Minor

CONSENT TO MEDICAL TREATMENT OF MINOR

I hereby authorize any duly authorized doctor, emergency medical technician, hospital or other medical facility to treat said minor for the purpose of attempting to treat or relieve any injuries received by said minor while he/she was a participant or observer at the “DIXIE ROCK 19 CLIMBING COMPETITION”.

I authorize any licensed physician to perform any procedure, which he/she deems advisable in attempt to treat or relieve any injuries or any related unhealthy conditions of said minor that he/she may encounter during any necessary operation.

I consent to the administration of anesthesia as deemed advisable by any licensed physician.

I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume any such risk on the behalf of myself and said minor. I acknowledge that no warranty is being made as to the results of any treatment.

______Printed Name Date

______Signature

______Parent or guardian signature if participant is a Minor

______Relationship to Minor FORM – DR19 2 0F 2 P/G WAIVER