| PARTICIPANT NAME:______________________________________________Age _____
[F | M] Contact: phone ( ) _____________ fax (
) _____________ e-mail ______________________
Activity:_________________________________________________________________________
Play Radium Registration:RELEASE OF LIABILITY AND WAIVERBy signing this document I agree to waive certain legal rights, including the right to sue. I,____________________ (parent or guardian) ___________________________________ (address) recognize that there are risks, dangers and hazards, inherent to outdoor recreational activities. I willingly accept and am fully responsible for any such risk, including the possibility of personal injury, death, property damage or loss, resulting there from. Any individual participating in negligence or liability activity will be informed of their behaviour and permission to contact the guardian will be required. I, OR ( PARENT OR GUARDIAN) OF ______________________________ HAVE READ AND UNDERSTOOD this release of liability prior to signing it, and am aware that by signing this release of liability I am waiving certain legal rights which I or my heirs, next of kin, executors, administrators, and assign may have against such releases. SIGNED THIS________________________________DAY OF ________________________2002 SIGNATURE OF GUARDIAN, PARENT:______________________________________________ WITNESS: _______________________________________________________________________
For information contact the Radium Village office at (250) 347-6455
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