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Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Do you have any underlying medical health issues or injuries? *

(e.g asthma, diabetes etc..)

Yes

No

Medical Waiver - Please read the following and tick the box at the bottom. *

ACKNOWLEDGMENT OF WARNING, WAIVER, RELEASE AND CONSENT FOR PARTICIPATING IN A DANGEROUS ACTIVITY RE: AgileX Performance Participation   I, or the person/s on whose behalf I am signing, wish to participate in the above activity.   I acknowledge that I/they have been warned this activity is inherently dangerous and carries with it potential risks including the risk of death, serious injury and other damage to my person and property.   I/they freely and voluntarily accept and assume all risks of participating in this activity and in doing so I confirm that:   -            I am over the age of 18 years with full capacity to understand the warning, to sign this waiver on my own behalf and provide my consent or I am the parent/guardian of a minor and have full capacity and authority to sign and provide consent on their behalf;   -            I/they have a level of fitness and proficiency sufficient to safely participate in the activity; and   -            I am not aware of any medical condition which may preclude or limit my/their ability to participate in the activity.   In consideration for being permitted to participate in this activity, to the maximum extent permissible at law, I/they:   -            waive, release, and discharge  Unopened Matters from all liability for my/their death, disability, personal injury and property damage in any way arising out of my/their participation in the activity and acknowledge that this waiver and release extends to their directors, officers, employees, volunteers, representatives, agents and sponsors.   I acknowledge and intend that this waiver and release binds me, my executors, administrators, heirs and successors, or where applicable binds the persons on whose behalf I am signing and their executors, administrators, heirs and successors.   I consent to receive, or if applicable to the persons on whose behalf I am signing receiving, any reasonably appropriate medical treatment that may be deemed necessary or advisable by a certified first aid officer, registered paramedic, or medical practitioner in the event of any injury, accident or illness suffered while participating in this activity.   I consent to my/their participation in the activity being photographed or filmed and such images being used for any legitimate commercial purposes including marketing and social media posting by  Unopened Matters or their permitted directors, officers, employees, volunteers, representatives, agents and sponsors

I have read and understood the following medical waiver