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17
MEDICAL QUESTIONNAIRE
Do you have any current or recurrent medical problems for which you are being seen by a doctor?
YES____ NO____ If yes: ___________________________________________
Are you on any medication?
YES____ NO____ If yes: ___________________________________________
Are you allergic to any medication?
YES____ NO____ If yes: ___________________________________________
Are you hypersensitive to insect stings?
YES____ NO____ If yes: ___________________________________________
Comments: ______________________________________________________________________________________
______________________________________________________________________________________
WAIVER, RELEASE AND INDEMNIFICATION STATEMENT
In consideration of being allowed to participate in any way in the World Challenge Decatriathlon 2008, related events and activities, the
undersigned acknowledges, appreciates, and agrees that:
1. The risk of injury from the activities involved in the Decatriathlon 2008 is significant and includes, but is not limited to, the following: Drowning, near-
drowning, sprains, strains, fractures, heat and cold injuries, over-use syndrome, injuries involving vehicles, animal bites and stings, contact with poisonous
plants, accidents involving, but not limited to; swimming, biking, running, or other convenience, and the potential for permanent paralysis and death. While
particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist.
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE
RELEASEES or others, and assume full responsibility for my participation to the fullest extent of the law.
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard
during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official.
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS
the organizers of Decatriathlon 2008, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers,
volunteers, and if applicable, owners and lessors of premises used to conduct the event (“Releases”), WITH RESPECT TO ANY AND ALL INJURY,
DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE,
to the fullest extent permitted by law.
5. I further state that I am in proper physical condition to participate in this event and am over 18 years of age (or have a parental waiver).
6. The Releases reserve the right to postpone, cancel, or modify the event due to weather conditions or other factors beyond the control of the releases
which might affect the health or safety of the participants. No refunds will be granted.
7. I grant permission for the use of my name and or likeness related to my participation in any event conducted by the organizers of the Decatriathlon
2008, I also grant the use of my voice and any and all recorded and or filmed/video/photographed footage of me, and further waive all rights to any
compensation, as a result of my name or likeness being used in any way.
8. The organization of the Decatriathlon 2008 does not accept responsibility for refunds for cancellations in the event of natural or national emergencies.
Natural emergencies may include, but are not limited to severe weather including heavy rain, snow, tornados, hurricanes, river flooding, heat spells and
cold spells. National or international emergencies may include, but are not limited to military conflicts, terrorist attacks, security threats, war, & heightened
security alerts.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTOOD ITS
TERMS, UNDERSTOOD THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND
VOLUNTARILY WITHOUT ANY INDUCEMENT.
______________________________________________________
SIGNATURE OF PARTICIPANT DATE
_______________________________________________________________
PRINTED NAME OF PARTICIPANT
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