732- 383 5074
It is the responsibility of the participant
or parent/guardian to completely fill out this form and then sign the form before
participating in any Sailability New Jersey
Print name________________________________________________________ Phone
___________________
Address___________________________________________________________________________
City, State,
Zip___________________________________________________email______________________
Organization
Affiliation________________________________Date_____________________
Check Status: Participant
Instructor Volunteer Student
Guest Other_______________
Are you currently under a
doctor’s care? Yes No Are you prone to
startle reflex of seizures? Yes No
Emergency Contact: Name_________________________________
Phone______________________
Circle Disability Status: Blind
Deaf Developmentally
Disabled Physical-(type)________________
Circle Status: Caucasian
Afro-American Hispanic Asian
Other____________
In consideration of
Sailability New Jersey, Inc. extending to me the privilege of participating in
its water sports program, I fully assume all risk and waive all liability in
connection with my participation in any program, and in particular, without
limitation, to the extent permitted by law. I and my heirs, representatives,
executors, or administrators and my undersigned parent or guardian (if
applicable) remise, release, indemnify, acquit and hold harmless and forever
discharge Sailability New Jersey, Inc., it’s directors, employees, agents,
instructors, including volunteers, rescue and support personnel, from any and
all liabilities, obligations, damages, claims, causes of action, judgments,
costs, and charges which I may have or which may be incurred by me for reason
of any occurrence during my travel to and from the event, or during my
participation therein, whether resulting from acts or omissions of any persons,
from the operation or condition of facilities or premises, or from acts of god
or nature.
I hereby agree to comply with
all rules and regulations, give my permission for the free use of my name and
picture in any media account of the Sailability New Jersey, Inc. water sports
program(s) or any future public relations of fund raising activity. I also
agree to assume liability for any and all damages to Sailability New Jersey,
Inc. property that is under my control while participating in any Sailability New Jersey, Inc. activity.
SIGNATURE__________________________________________________Date___________________________
For participants under 18, I,
__________________________________________________ hereby affirm that my
child/ward has permission to participate in the Sailability
New Jersey Inc. water sports program.
SIGNATURE___________________________________________________Date____________________