CULPEPER COUNTY SHERIFF’S OFFICE
RELEASE OF ALL CLAIMS AND ASSUMPTION OF THE RISK
WHEREAS, I wish to voluntarily participate for my own
benefit in the following “Activity” sponsored by Culpeper County Sheriff’s
Office: SHERIFF SCOTT H. JENKINS 1ST ANNUAL POLICE WEEK 5K on the following date(s): MAY 17, 2014; and the County is
willing to permit my participation in the Activity because doing so serves
important government functions such as public education; and
I have been given specific information orally and/or in writing describing the
nature of the Activity and the risks and dangers involved, as well as
instructions relating to my participation in the Activity; and I have examined
the equipment and vehicles to be used in the Activity and find them safe and
suitable for my needs;
THEREFORE, I agree as follows: I have
listened to and/or read the information about the Activity and I understand the
nature of the Activity and its risks and dangers. I acknowledge that the County has taken all
reasonable steps to prepare me and properly equip me for the Activity. However, the County has warned me that
despite the County’s reasonable efforts, I could suffer serious bodily injury,
death and property damage as a result of the Activity, including but not
limited to physical or personal injury, disease, psychological or mental injury,
death and/or loss of property due to vehicle collision or malfunction, exposure
to fires or harmful substances, crashes, falls, overexertion, allergic
reaction, equipment or system failure, or other causes due to exposure to or
involvement in emergency or non-emergency situations.
such warning, and with full and complete understanding of all dangers and risks
the Activity involves, I voluntarily assume full responsibility and all risks
for any and all personal and bodily injuries, death and property damage that
may result to me from my participation in the Activity, and I assume all risks
inherent to this activity.
CERTIFY that I am physically capable of safely participating in the Activity,
and I have taken all actions that I consider necessary to make this
determination, up to and including seeking the advice of and appropriate
examinations by a qualified physician.
Should I require any reasonable accommodation I have made my needs known
to the County and I agree to abide by the County’s decision as to whether it
can accommodate my needs and, if so, how such accommodation is to be made.
CONSIDERATION of being allowed to participate in the Activity, I hereby waive,
release and forever discharge the Culpeper County Sheriff’s Office, Culpeper
County Board of Supervisors, their officers, directors, employees, agents and
volunteers (the “County”) from any and all claims, liabilities, actions and
causes of action of every nature and kind arising out of or relating in any way
to the Activity.
AGREE to indemnify and hold harmless the County from any and all personal and
bodily injuries, death and property damage, including cost of investigation,
reasonable attorney’s fees and cost of appeals, arising out of any such claims
or suits because of any acts or omissions by me. During and after the Activity
and while on County property I will abide by all instructions and restrictions
imposed by the County, including but not limited to instructions as to how I
should act and the use of equipment, and I agree that the County may
discontinue the Activity or require me to leave the premises at any time for
any reason. I authorize the County to
seek emergency medical treatment for me and to arrange for my transportation to
a medical facility in the event of a medical emergency.
CERTIFY that I am over eighteen (18) years of age and am mentally
competent. This Release and Assumption
of Risk is binding on all my heirs, executors, next of kin and assigns, and all
persons who may claim by or through me.
I acknowledge that the County offers me no worker’s compensation,
medical payments coverage, or other benefits in connection with the Activity.
CAUTION: READ THE FOREGOING RELEASE OF ALL CLAIMS AND
ASSUMPTION OF RISK BEFORE SIGNING. THIS
DOCUMENT IS VALID UNLESS AND UNTIL REVOKED IN WRITING AND REVOCATION DELIVERED
TO CULPEPER COUNTY.