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Coastrek Risk Waiver

Wild Women on Top Sydney Coastrek
5-6 March 2010
Palm Beach to Coogee
How far can YOUR team walk?
 
Please ensure that each individual in your team has completed and submitted a Risk Waiver. If you make a change to your team, the replacement person will also need to complete a Risk Waiver prior to taking part in the event.
Name*
Mobile Number*
Email address*
(email address)
Date of Birth*
(DD/MM/YYYY)
Team Name*
Team Captain's Name*
Category*
Emergency Contact Person*
Emergency Contact Person's Number*
Today's Date*
(DD/MM/YYYY)
How did you hear about Coastrek?*
Are you currently a Wild Women on Top Member?*
Would you like to subscribe to our Wild Women Weekly Newsletter?*
YES NO
Initials-please place your initials here & then against each of the below clauses to acknowledge that you agree to them*
I acknowledge that the activity involves certain inherent risks of injury as a result of walking on uneven, steep or rocky surfaces, and by torch light in the open natural environment and under prevailing weather conditions.*
I acknowledge that in addition the activities may be subject to risks associated with the equipment used and/or travelling to the sites or locations used.*
I acknowledge that the injuries may require treatment at a medical facility or hospital and/or may result in death or permanent disablement.*
I acknowledge that the activities may be conducted at a site that is remote either by time and/or distance from a medical facility or hospital.*
I acknowledge that the activities may be physically demanding in some susceptible individuals and may involve exposure to the natural elements and extreme weather and other circumstances over which the company has no control.*
I further state that I am of lawful age and legally competent to sign this acknowledgement or that I have acquired the written consent of my parent or guardian. *
I understand that the terms herein are contractual, serious not a mere recital and form the basis of the Agreement by which I participate; and that I have signed this document of my own free act.*
I further acknowledge that having been advised of the associated risks, I wish to undertake the Coastrek event with the company.*
I further acknowledge that having been advised of the associated risks, I wish to undertake the event & hereby release & hold harmless the company & its employees from any suit/demand/claim arising as a consequence of my participation*
I further acknowledge that I release and hold harmless the company from any claim arising as a consequence of death, disablement, injury or loss of any kind suffered during, or arising by any means as a result of my participation in the said activities.*
I further acknowledge that I have been advised by the principals, servants and/or agents of Wild Women on Top, of the risks associated with the activities and to the extent permitted by law, I have voluntarily assumed those risks.*
I understand that nothing in this contract limits or excludes provisions made in the Trade Practices Act (Cwlth) 1974 or other applicable legislation and that despite my signing of this contract I will still have the benefit of consumer protection.*
I acknowledge this Agreement is governed by the Laws of NSW including the Civil Liability Act 2002 as amended.*
I further acknowledge that this document may be relied upon in any proceedings instituted in any Court by me or my heirs, executors and assigns*
I have read & understood the Rules & Guidelines of Coastrek, including the requirement that I wear a reflective jacket/vest when on/near roads & on the night of the event.*
I agree to inform Wild Women on Top of any pre-exisiting Medical conditions or injuries before taking part in any physical activities*
I acknowledge that the organisers of the Sydney Coastrek strongly recommend that as an individual I arrange for Ambulance Cover, in case of emergency*
I acknowledge that the Event Organiser may change the advertised course without notice. *
I acknowledge that the event organisers may cancel the event due to weather conditions, natural disaster, acts of god, terrorism, war or any other reason so deemed by the organisers as unsuitable & that the event will be rescheduled, where possible.*
I acknowledge that if the event has to be rescheduled or cancelled for reasons outside of the control of the organiser, that my entry fee is non-refundable.*
Name*
Initials / Initials of Guardian if under 18yrs of age*
Verify*
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