BTI Whitewater Zip Line
RELEASE, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
NO ONE WILL BE ALLOWED TO RENT EQUIPMENT OR USE BTI WHITEWATER SERVICES WITHOUT SIGNATURE AND RETURN OF THIS AGREEMENT; READ ALL PAGES OF THIS AGREEMENT CAREFULLY AND ONLY SIGN IF YOU UNDERSTAND AND AGREE TO THE PROVISIONS HEREIN. A SEPARATE FORM MUST BE COMPLETED AND SIGNED FOR EACH EQUIPMENT RENTER/PARTICIPANT, WHETHER ADULT OR CHILD. A SIGNATURE FOR A CHILD CAN ONLY BE GIVEN BY A PARENT OR COURT APPOINTED LEGAL GUARDIAN, OR BY AN ACCOMPANYING ADULT PROVIDING US WITH A COPY OF A CURRENT NOTARIZED AUTHORIZATION TO ACT FROM THE CHILD’S PARENT OR LEGAL GUARDIAN. ALL CHILDREN MUST BE ACCOMPANIED AND SUPERVISED BY AN ADULT OTHER THAN A BTI WHITEWATER STAFF PERSON.
(A SEPARATE FORM MUST BE COMPLETED FOR EACH PARTICIPANT)
In consideration of being allowed to participate in Loudoun Adventures, LLC, Butts Tubes, Inc, d/b/a BTI Whitewater, Zip Line (the “Activity”), I represent that I understand the nature of this Activity and that I am qualified, in good health, and in proper physical condition to participate in the Activity, which involves travel on Zip Lines (sliding on elevated steel cables using safety harnesses). I agree to only participate while wearing the protective and safety equipment required, to follow the instructions of the guides and, if I believe it unsafe, to immediately discontinue my participation. I know that this Activity involves risks of serious bodily injury, including permanent disability, paralysis and death, and damage or loss of personal property which may be caused by my own actions or inactions, by others participating in the Activity, or by the conditions in which the Activity takes place including, but not limited to, the risks of falling; travel through and over rough terrain by foot or other means while participating; the failure or misuse of equipment; the risks that injuries may occur in remote areas without adequate medical facilities; collision with other people or objects; and bites from insects, snakes or animals. I realize that there may be other risks not now known or not readily foreseeable but I fully accept and assume all such risks, whether or not identified above, and I assume all responsibility for injury, loss or damage which I suffer as a result of my participation.
The Releasees identified below may also have been requested to arrange for my participation in activities or services, including lodging or meals, provided by others (“Additional Services”) and I acknowledge that the Releasees have made no representations whatsoever as to the safety or quality of those Additional Services.
I HEREBY RELEASE Loudoun Adventures , LLC, Butts Tubes, Inc, d/b/a BTI Whitewater and all property owners any parent, related and/or subsidiary corporations, partnerships, companies and entities; their respective administrators, directors, agents, officers, volunteers, and employees; other participants; sponsors; advertisers; and the owners and lessors of the property on which the Activity takes place (the “Releasees”) from all liability, claims, demands, losses, costs and damages arising or asserted to arise, directly or indirectly, in whole or in part, from the Activity or the Additional Services whether resulting from negligence or otherwise, including rescue operations, and will indemnify and hold harmless the Releasees as to all such matters.
I consent to the use without compensation by Releasees of photographs and video recordings made of me or the minor identified below while participating in the Activity or using the Additional Services without compensation and agree that all such materials including negatives, are the sole property of the Releasees.
I agree that the exclusive venue of any suit or claim against the Releasees for any reason whatsoever shall be the Magistrate or Circuit Courts of Loudoun County, Virginia; consent to the jurisdiction of such Courts as to any action against me to enforce this Agreement; and agree that this Agreement is to be enforced in accordance with the law of the State of Virginia.
I have read the foregoing Release, Assumption of Risk And Indemnity Agreement; understand that I will give up substantial rights by signing it; sign it freely and without any inducement or assurance of any nature not stated herein; intend it to be a complete and unconditional release, assumption of risk and indemnity to the greatest extent allowed by law; and agree that if any portion of this Agreement is held invalid the remainder shall continue in full force and effect.
MEDICAL INFORMATION
DO YOU HAVE ANY PREEXISTING MEDICAL CONDITIONS?
(Please list conditions such as allergies, recent surgery, conditions that require medication, circulatory or respiratory conditions, and any other conditions that you may have.)
NO _______ YES _______
IF YES, PLEASE EXPLAIN:___________________________________________________________________
Due to health risks, persons who are pregnant, have cardiac issues or other health problems will be prohibited from participating in zip line activities.
Printed Name of
PLEASE PRINT
FIRST NAME:_____________________________ LAST NAME:__________________________________
STREET:_____________________________________________________________________________
CITY:__________________________________ STATE: ________________ ZIP CODE: ______________
DAY TIME PHONE:__________________________ EVENING PHONE:___________________________
AGE:____________________DATE OF BIRTH:________________________________________________
To receive our e-newsletters, specials, hot deals, high water alerts or other information, please give your email address!
EMAIL ADDRESS:_________________________________________________________________
SIGNATURE:_____________________________________________ DATE:_______________
IF PARTICIPANT IS NOT AGE 18 OR OVER, COMPLETE ALL OF THE FOLLOWING:
PRINT NAME OF ACCOMPANYING AND SUPERVISING ADULT: ____________________________________________________________________________________
PRINT NAME, RESIDENCE ADDRESS, ZIP CODE AND HOME PHONE NUMBER OF PARENT, LEGAL GUARDIAN OR AUTHORIZED ADULT SIGNING THIS FORM: (PLEASE NOTE, THE ONLY “LEGAL GUARDIAN” WHO CAN SIGN IS ONE WHO HAS BEEN FORMALLY APPOINTED BY AN ORDER OF COURT. THE ONLY “AUTHORIZED ADULT” IS AN ADULT WHO HAS IN HAND A COPY TO GIVE US OFA NOTARIZED DOCUMENT SIGNED BY THE PARENT OR LEGAL GUARDIAN WHICH CLEARLY AUTHORIZES THE ADULT TO SIGN AGREEMENTS SUCH AS THESE ON BEHALF OF THE CHILD):
PRINT NAME__________________________________________________________________
ADDRESS__________________________________________________________________
__________________________________________________________________
PHONE NUMBER WITH AREA CODE
__(_________)___________-__________________________________
SIGNATURE_________________________________________________ DATE__________
