MRSS Ka-Vroom 2011

Soapbox Derby
(June 18th, 2011)

RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS

AND INDEMNITY AGREEMENT

ATTENTION: BY SIGNING THIS FORM YOU ARE ACCEPTING THE RISKS INVOLVED
IN PARTICIPATING IN KA-VROOM!
PLEASE READ CAREFULLY! ALL PARTICIPANTS MUST BE AGES 5-14
NAME OF PARTICIPANT: ______________________________________________________________________________
NAME OF PARENT OR GUARDIAN: ____________________________________________________________________
ADDRESS OF PARTICIPANT:___________________________________________________________________________
TELEPHONE NO (1): _____________________________________ BIRTH DATE: DD!
_____________________
MM! YYYY
TELEPHONE NO (2): _____________________________________
EMAIL OF PARENT OR GUARDIAN (1):_________________________________________________________________
EMAIL OF PARENT OR GUARDIAN (2):_________________________________________________________________

DISCLAIMER CLAUSE
Ka-Vroom, its volunteers, and representatives (furthermore to be known as the Ka-Vroom Team
and representing Maple Ridge Secondary School) are not responsible for any injury, loss or damage
of any kind sustained by any person while participating in Ka-Vroom. You are entering in this event
at YOUR OWN RISK.

INDEMNIFICATION AND RELEASE OF LIABILITY

In return for the Ka-Vroom Team allowing my child to voluntarily participate in the Ka-Vroom and
related activities, I agree:
1. TO ASSUME AND ACCEPT ALL RISKS arising out of, associated with, or related to my
participating in the Ka-Vroom event;
2. TO BE SOLELY RESPONSIBLE FOR ANY INJURY, LOSS OR DAMAGE which I
might sustain while participating in Ka-Vroom;
3. TO HOLD HARMLESS AND INDEMNIFY THE KA-VROOM TEAM:
a) From any and all liability for any damage to the personal property of, or personal injury to,
any third party resulting from my participation in Ka-Vroom and all related activities; and
b) From any and all claims, demands, actions and costs that might arise out of my participating
in the Ka-Vroom event.

PERMISSION TO USE PHOTOGRAPHS

In return for the Ka-Vroom Team allowing my child to participate in this event, I give the Ka-
Vroom Team permission to use his/her photographs for promotional purposes including, but not
limited to, a promotional video/newsletter. I acknowledge that by signing this form, the Ka-Vroom
Team can publish photographs of myself or my child without any further notification.

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 Protection of Privacy - The personal information requested on this form will be protected. It will
be used for the purpose of implementing this waiver. Direct any questions about this collection to: Karen Aitken
(Ka-Vroom Coordinator) or the MRSS Ka-Vroom Team at
Email: kavroommrss@gmail.com
Phone: (604) 463-4175 ext. 1119

Signed this _______ day of ______________________________, 20____

__________________________________________ ________________________________________
Signature of Participant Signature of Parent/Guardian

__________________________________________ ________________________________________
Printed Name of Participant Printed Name of Parent/Guardian

_______________________________________________________________________________
Note: Document must be copied to a single page back to back when used.
Signed documents must be brought to MRSS (Maple Ridge Secondary School) upon signing.
For more information, visit the official Ka-Vroom Website: mrsska-vroom.blogspot.com
Updated: November, 2010

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