HomeMy WebLinkAboutRelease of Claims - Waiver Form - 5-23-2006
RELEASE OF CLAIMS
This Release of Claims is made on ____________________________, 20__________, by
______________________________________, whose date of birth is ___________________,
(Name of Participant)
and whose address is __________________________________________________________.
(Street Address/P. O. Box #) (Town/City) (State) (Zip Code)
In consideration of the permission granted to me by the County of Hawaii, State of
Hawaii, to participate in _________________________________________________________
(Description of Activity)
program at ___________________________________________________________________
(Name and Address of Facility)
(hereafter Facility) from ___________________, 20______, to ________________, 20______,
(Dates of Activity)
I hereby release the County of Hawaii, its agents, independent contractors, and employees from all
actions, causes of action, damages, claims or demands, which I, my heirs, personal representatives, or
assignees may have against the County of Hawaii, and other above-named parties for all injuries, known
or unknown, which may incur by my participation in the above-described activity or by my use of the
above-described Facility.
I do further agree that I shall indemnify and save harmless the County of Hawaii, or any of its officers
or employees, either jointly or severally, from any and all claims, demands, damages, loss of service, or
expense for property damage and for personal injuries or actions brought by a third party resulting or
arising from my participation in the above-described activity or my use of the Facility.
I, the undersigned, have read this Release and understand all of its terms. I execute it voluntarily
and with full knowledge of its significance.
IN WITNESS WHEREOF, I have executed this Release at _________________________________,
on the day and year first written above. (Place of Execution)
_________________________________________
Participants Signature Telephone No.
If Participant is under 18 years of age:
__________________________________________
Signature of Parent or Guardian Telephone No.
_______________________________________ __________________________________________
Printed Name of Witness (age 18 or older) Witnesss Signature Telephone No.
(All signatures require a witness) (All signatures require a witness signature)
5/23/06