Gallop for a cure waiver
Please sign and return both waivers, with $35 FOR ADULTS AND $10 for children under 15 check payable to
The Montel Williams Foundation to:
Christi Medice 6394 Whittington Road, Exmore Virginia 23350
RIDE AT OWN RISK
In consideration for receiving permission to participate in the MS Gallop For A Cure (herein referred to as ACTIVITY), which is sponsored
by Christi Medice, Rose Payne, Glen Payne, Furnace Town Living Heritage Museum, Pocomoke Forest and Montel Williams MS
Foundation for MS Research and their officers, agents, volunteers, or employees (herein referred to as RELEASEES) from any and all
liabilities, claims, demands or injury, including death, that may be sustained by me while participating in such activity, or while on the
premises owned or leased by the releasees. I acknowledge that there may be physically strenuous activities, and know of no medical
reason why I should not participate.
(Initial)________ I am fully aware that there are inherent risks involved with the activity.
(Initial)_______ The likelihood of the inherent risks becoming hazardous to myself and/or my property can be reduced.
(Initial)________ Knowing this information, I choose to voluntarily participate in the activity with full knowledge that the activity may be
hazardous to myself and/or my property. I voluntarily assume full responsibility any risk of loss, property damage or personal injury,
including death, that may be sustained by me as a result of participating in the activity. I further agree to indemnify and hold harmless the
releasees for any loss, liability, damage or cost, including court cost and attorney's fees, that may occur as a result of my participation in
the activity.
(Initial)________I understand that the releasees so do not maintain any insurance policy covering any circumstance arising from my
participation in this activity or any event related to that participation. As such, I am aware that I should review my personal insurance
coverage.
(Initial)________It is my express intent that this Covenant Not To Sue and Agreement to Hold Harmless shall bind the members of my
family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws
of Maryland.
(Initial)_______In signing this Covenant Not To Sue and Agreement to Hold Harmless, I acknowledge and represent that I have read the
foregoing Covenant Not To Sue and Agreement to Hold Harmless, understand it and sign it voluntarily as my own free act and deed. I
acknowledge and represent that no oral representations, statements, or inducements apart from the foregoing agreement that has been
reduced to writing have been made. I execute this document for full, adequate and complete consideration fully intending to be bound by
the same, now and in the future.
Signed this__________ day of_______________, 20___
Participant Signature______________________________Local
Address______________________________________________________
Printed Name___________________________________________Local
Phone________________________________________________
Parent or Legal Guardian Signature_________________________________________________________________________
(Signature required if Participant is under 18 years old)
Witness Signature____________________________________________________________________________
Printed Name____________________________________________________________________
In case of emergency, contact_____________________________________________ at the following
number_______________________________
Please list any special services you may require due to existing medical condition or physical
disability__________________________________________
Please provide shirt size and number requested (first one free, others are $15)__________________
EMAIL ADDRESS_______________________________________
Please sign and return both waivers, with $35 FOR ADULTS AND $10 for children under 15 check payable to
The Montel Williams Foundation to:
Christi Medice 6394 Whittington Road, Exmore Virginia 23350
RIDE AT OWN RISK
In consideration for receiving permission to participate in the MS Gallop For A Cure (herein referred to as ACTIVITY), which is sponsored
by Christi Medice, Rose Payne, Glen Payne, Furnace Town Living Heritage Museum, Pocomoke Forest and Montel Williams MS
Foundation for MS Research and their officers, agents, volunteers, or employees (herein referred to as RELEASEES) from any and all
liabilities, claims, demands or injury, including death, that may be sustained by me while participating in such activity, or while on the
premises owned or leased by the releasees. I acknowledge that there may be physically strenuous activities, and know of no medical
reason why I should not participate.
(Initial)________ I am fully aware that there are inherent risks involved with the activity.
(Initial)_______ The likelihood of the inherent risks becoming hazardous to myself and/or my property can be reduced.
(Initial)________ Knowing this information, I choose to voluntarily participate in the activity with full knowledge that the activity may be
hazardous to myself and/or my property. I voluntarily assume full responsibility any risk of loss, property damage or personal injury,
including death, that may be sustained by me as a result of participating in the activity. I further agree to indemnify and hold harmless the
releasees for any loss, liability, damage or cost, including court cost and attorney's fees, that may occur as a result of my participation in
the activity.
(Initial)________I understand that the releasees so do not maintain any insurance policy covering any circumstance arising from my
participation in this activity or any event related to that participation. As such, I am aware that I should review my personal insurance
coverage.
(Initial)________It is my express intent that this Covenant Not To Sue and Agreement to Hold Harmless shall bind the members of my
family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws
of Maryland.
(Initial)_______In signing this Covenant Not To Sue and Agreement to Hold Harmless, I acknowledge and represent that I have read the
foregoing Covenant Not To Sue and Agreement to Hold Harmless, understand it and sign it voluntarily as my own free act and deed. I
acknowledge and represent that no oral representations, statements, or inducements apart from the foregoing agreement that has been
reduced to writing have been made. I execute this document for full, adequate and complete consideration fully intending to be bound by
the same, now and in the future.
Signed this__________ day of_______________, 20___
Participant Signature______________________________Local
Address______________________________________________________
Printed Name___________________________________________Local
Phone________________________________________________
Parent or Legal Guardian Signature_________________________________________________________________________
(Signature required if Participant is under 18 years old)
Witness Signature____________________________________________________________________________
Printed Name____________________________________________________________________
In case of emergency, contact_____________________________________________ at the following
number_______________________________
Please list any special services you may require due to existing medical condition or physical
disability__________________________________________
Please provide shirt size and number requested (first one free, others are $15)__________________
EMAIL ADDRESS_______________________________________
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