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MEDICAL QUESTIONNAIRE
Do you have any current or recurrent medical problems for which you are being seen by a doctor?
YES____ NO____ If yes: ___________________________________________
Are you on any medication?
YES____ NO____ If yes: ___________________________________________
Are you allergic to any medication?
YES____ NO____ If yes: ___________________________________________
Are you hypersensitive to insect stings?
YES____ NO____ If yes: ___________________________________________
Comments: ______________________________________________________________________________________
______________________________________________________________________________________
WAIVER, RELEASE AND INDEMNIFICATION STATEMENT
In consideration of being allowed to participate in any way in the Double Decatriathlon 2010 World Challenge, related
events and activities, the undersigned acknowledges, appreciates, and agrees that:
1. The risk of injury from the activities involved in the Double Decatriathlon World Challenge 2010 is significant and includes,
but is not limited to, the following: Drowning, near-drowning, sprains, strains, fractures, heat and cold injuries, over-use
syndrome, injuries involving vehicles, animal bites and stings, contact with poisonous plants, accidents involving, but not limited
to; swimming, biking, running, or other convenience, and the potential for permanent paralysis and death. While particular rules,
equipment, and personal discipline may reduce this risk, the risk of serious injury does exist.
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM
THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation to the fullest extent of
the law.
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any
unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the
attention of the nearest official.
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY,
AND HOLD HARMLESS the organizers of Double Decatriathlon World Challenge 2010, their officers, officials, agents and/or
employees, other participants, sponsoring agencies, sponsors, advertisers, volunteers, and if applicable, owners and lessors of
premises used to conduct the event (“Releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or
damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the
fullest extent permitted by law.
5. I further state that I am in proper physical condition to participate in this event and am over 18 years of age (or have a parental
waiver).
6. The Releases reserve the right to postpone, cancel, or modify the event due to weather conditions or other factors beyond the
control of the releases which might affect the health or safety of the participants. No refunds will be granted.
7. I grant permission for the use of my name and or likeness related to my participation in any event conducted by the organizers
of the Double Decatriathlon World Challenge 2010, I also grant the use of my voice and any and all recorded and or
filmed/video/photographed footage of me, and further waive all rights to any compensation, as a result of my name or likeness
being used in any way.
8. The organization of the Double Decatriathlon World Challenge 2010 does not accept responsibility for refunds for
cancellations in the event of natural or national emergencies. Natural emergencies may include, but are not limited to severe
weather including heavy rain, snow, tornados, hurricanes, river flooding, heat spells and cold spells. National or international
emergencies may include, but are not limited to military conflicts, terrorist attacks, security threats, war, & heightened security
alerts.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY
UNDERSTOOD ITS TERMS, UNDERSTOOD THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY
SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
______________________________________________________
SIGNATURE OF PARTICIPANT DATE
_______________________________________________________________
PRINTED NAME OF PARTICIPANT
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