Sample Accident Waiver and Release of Liability Form

ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM

I _________________________, of legal, age Filipino, and a resident of

________________________, after having been sworn in accordance with law, hereby depose and
state:

1. I have freely and voluntarily chosen to participate in the __________________

(“Event”), to be held on the __ day of ______, at _________________, organized by
______________________________,

2. I fully understand that by participating in the Event, I might encounter activities

which might expose me to physical harm, danger, or risks, which might be beyond the control of
the Company, or any of the organizers of the event.

3. In connection with the said Event, I hereby release and forever discharge and agree
to save and hold harmless ____________________________________, their officials, employees,
representatives or assigns and the activity and event organizers to any and all injuries (including
personal injury, disability, dismemberment, and death), illness, losses, damages, claims, liabilities
or expenses of any kind or nature accruing to me, my heirs or my personal representatives that
are caused or alleged to be caused on whole or in part by my action, fault, omission, failure to act,
or by my breach or alleged breach of this waiver and release, or by the condition of the property,
facilities or equipment of any released party or that arise out of or in connection with the office
activity.

4. This accident waiver and release of liability shall be construed broadly to provide
a release and waiver to the maximum extent permissible under applicable law. I agree that in the
event that any clause or provision of this Release shall be held to be invalid by any court of
competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the
remaining provision of this Release which shall continue to be enforceable.

5. I represent and warrant that I am authorized to enter into this Release and that I
have obtained or do not require the consent of any third party to enter into this Release.

6. I fully understand the contents of this waiver, and I execute this freely and
voluntarily.

IN WITNESS WHEREOF, I hereunto set my hand this ___ day of __________, at

____________, Philippines.

______________________
Participant-Affiant

ACKNOWLEDGEMENT

BEFORE ME, on this ___ day of ____________ at ________, personally appeared Mr./Ms.
_____________, who presented to me his ____________ as competent evidence of identity and
therefore, he is known to me and to me known to me the same person who executed this Accident
Waiver and Release of Liability Form, consisting of one (1) page, and certify the same as his free
and voluntary act and deed.

Doc No. ____;

Page No. ____;
Book No. ____;
Series of 20 ___.