By signing this Waiver, I assume all risk of my child and/or myself participating in
________________________ with Lawrence County Shine, LLC.. Without signing this form,
neither myself nor my child will be able to participate in the activity. I acknowledge that the
above activity may pose some risk of personal injury and that I undertake and assume this risk
for myself and my child. On behalf of myself and my child, I further waive and release the
promoters of the activity, any insuring entity of the above, and their directors, board members,
officers, employees, volunteers, agents, representatives, or assigns, as well as the activity
sponsors, from any and all liability, including, but not limited to, liability arising from negligence
or fault of the entities or persons for any injury or disability which may occur as a result of my or
my child’s participation in the above activity. I am assuming all risks on behalf of myself and my
child that may arise from negligence or carelessness on the part of any of the persons or
entities being released, as well as from defective equipment, real property or personal property
that is owned, maintained or controlled by the above persons.
I CERTIFY THAT MY CHILD AND MYSELF ARE PHYSICALLY FIT AND
SUFFICIENTLY PREPARED FOR PARTICIPATION IN THE ACTIVITY AND THAT THERE ARE
NO HEALTH RELATED REASONS OR PROBLEMS WHICH WOULD PRECLUDE THE
PARTICIPATION OF MYSELF OR MY CHILD IN THE ACTIVITY. I HAVE NOT BEEN ADVISED
OF ANY REASON WHICH WOULD LIMIT MY CHILD OR MYSELF IN PARTICIPATING IN THE
ACTIVITY.
I consent to receive any medical treatment deemed advisable for an injury to myself or
my child during the activity and that any medical or other insurance for myself and/or my child
will be insurance of first resort before contribution by any other insurance for any other person
or entity, accident medical insurance. I understand that I and/or my child may be photographed
while participating in the activity.
I agree to allow my and my child’s photo, video, or film likeness to be used for any
legitimate purpose by the activity holders, sponsors, producers, and their assigns. I shall
defend, hold harmless, and indemnify the parties from and against all losses, claims, damages,
costs or expenses (including reasonable legal fees, or similar costs) in connection with any
action or claim brought or made (or threatened to be brought or made), for, or on account of any
injuries or damages, received or sustained by myself and/or my child arising during the course
of the activity.
This Agreement constitutes the sole and only agreement between the parties concerning
my child’s and my release and indemnification as a condition for participating in this activity. Any
prior agreements, whether oral or in writing, shall be void and of no further effect. This
Agreement may not be modified. I certify that I have read this document, and I fully understand
its contents. I am aware that this is a release and indemnification of liability for myself and my
child, and I sign it of my own free will.