Waiver Form

Please READ and Sign below!

All students must fill out a waiver form prior to participating with Kids Helping Kids.  This form will be applicable for the entire time they work with KHK. Unfortunately, no student will be allowed to participate without a waiver form filled out and signed by an adult.

In consideration of my being permitted by Kids Helping Kids, Inc. [“KHK”] to participate and engage in any or all of the programs and activities conducted by it, its agents or representatives, and wherever the programs and activities are located, I understand and agree to the following things in return for the opportunity to participate:

ASSUMPTION OF RISK: I represent that I understand the nature of the various KHK program activities, that I am qualified, in good health and in proper physical condition to participate in these activities, and that if I have any questions or concerns about my health and/or ability to participate, I should consult with a physician beforehand. Additionally, if while participating, I consider or believe any circumstances to be uncomfortable, unacceptable and/or unsafe, I will immediately discontinue participation in the activity.

I understand that these activities may involve risks of bodily injury, minor to serious, which may be caused by my own actions or inactions, those actions or inactions of others who are participating in the activity, the weather, other conditions under which the activity takes place, or the negligence of the “Releasees” named below. There may also be other risks either not known to me or not readily foreseeable at this time and which cannot be completely eliminated regardless of the care taken. I fully accept and assume all such risks and all responsibility for any losses, costs, and damages I may incur as a result of my participation in the activity.

RELEASE AND WAIVER OF LIABILITY: I, for myself and for my heirs, personal representatives and assigns, do hereby release, waive, discharge, and covenant not to bring suit against, Kids Helping Kids, Inc., its affiliated or subsidiary companies, its officers, directors, employees, agents or representatives (whether compensated or not), its volunteers, participants, sponsors and advertisers, the owners or lessors of premises on which the activities are held, and any other party indemnified and held harmless by KHK, each considered to be one of the “Releasees” herein, from all liability, claims, demands, losses, or damages which I suffer caused or alleged to be caused in whole or in part by the negligence of the “Releasees.”

I further agree that if I or anyone on my behalf, despite this release, waiver of liability, and assumption of risk, makes a claim against any of the Releasees, I, or if applicable, my parent, guardian, personal representatives and assigns, will indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost or expense, including attorney’s fees and the costs of litigation, which any may incur as a result of such claim.

AUDIO-VISUAL RELEASE: I understand that while conducting its programs, KHK may make photographic, video and/or audio recordings of its activities and participants, including images captured or recorded using film cameras, digital cameras, analog or digital video recorders or any other reasonably-related devices capable of capturing or recording images, video and/or audio. I grant and convey to KHK an irrevocable and permanent right, title and interest in any such recordings, which may include me (or may include the participant, if under the age of 18), and to use them for any lawful purpose including derivation of economic or other benefit. This particular audio-visual release provision shall survive any revocation of this Agreement by me or by KHK tendered under the provision entitled “Effective Date and Term” appearing elsewhere in this Agreement.

ACKNOWLEDGEMENT: I have read this RELEASE AND WAIVER OF LIABILITY & INDEMNIFICATION AGREEMENT and understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature. I intend it to be a complete and unconditional release of all liability to the broadest and most comprehensive extent allowed by law, and I agree that if any portion of this Agreement is held to be invalid under the laws of my state of residence or the state or jurisdiction in which the activities are conducted, the balance, notwithstanding, shall continue in full force and effect so as to affect the intended release, waiver and indemnification to the greatest degree possible.

EFFECTIVE DATE AND TERM: This Agreement shall be effective when properly completed and signed and as of the date thereafter received by KHK. It shall remain effective until its revocation. I may revoke this Agreement at any time by delivering my written revocation to Kids Helping Kids, Inc., 110 Lenox Avenue, Suite 206, Stamford, CT 06906. However, if and when I revoke this Agreement, I (or the minor participant under age 18, if I am his or her parent or legal guardian) will immediately and totally cease to engage or participate in any and all activities sponsored or conducted by KHK or its agents or representatives, and the permission granted to me (or the minor participant) by KHK is simultaneously revoked and terminated. KHK may also revoke this Agreement at any time, and at its sole discretion, by delivering notice to the below address.

I understand that the words “Me,” “My,” or “I” which appear throughout this Agreement are intended to refer to me, a participant over age 18, or if appropriate, to the minor participant under age 18 for whom I am the parent or legal guardian.

I AGREE THAT I WILL NOT PARTICIPATE IN KHK ACTIVITIES UNTIL KHK HAS RECEIVED BOTH PAGES OF THIS SIGNED AND COMPLETED DOCUMENT AND HAS ACCEPTED ME (OR THE PARTICIPANT WHO IS UNDER AGE 18) AS A KHK PROGRAM PARTICIPANT.

NOTE: PLEASE COMPLETE, SIGN AND SUBMIT A SEPARATE AGREEMENT FOR EACH INDIVIDUAL PARTICIPANT, REGARDLESS OF AGE.

...
Loading