Contact Phone Number

(000-000-0000)

Emergency Contact

First and Last Name

Emergency Contact's Phone Number*

(000-000-0000)

Hosts:

I, the undersigned, understand and acknowledge that the program that I am about to attend and participate in is being presented by Kingdom of Northlands Belegarth Medieval Combat Society ( KoN BMCS) and is a member for the international organization known as Belegarth.  The Officers and their agents of KoN BMCS shall herein be known as Hosts.

Strenuous physical encounters:*

I, the undersigned, understand that participation in the events and practice sessions of KoN BMCS includes possible strenuous physical encounters between myself and others that could lead to serious physical discomfort, and, or, permanent impairment.

Risk of physical harm:

By digitally signing this release form, I give my full consent to such contact and physical activities that may cause me physical harm or death.  I hereby acknowledge that I fully realize that during the practices or events I will at all times have the option of withdrawing from participation in any exercise or combat, and that it is my personal responsibility to decide which exercises and combats that I will participate in.  I hereby also represent that I am physically and emotionally fit to engage in these combat activities.  I also acknowledge that the members of KoN BMCS are under no obligation to require me to prove my degree of health and fitness.  I further acknowledge that at any time during the practices or events I may be exposed to a risk of personal injury or death arising out of negligence, unavoidable accident, or otherwise, due to the very nature of the combat activities.

Field debris:

I understand that KoN BMCS, their officers, nor their agents, guarantee that the fighting field will be free from debris or defects.

Assuming all risks:

By signing this agreement and as part of the consideration for participating in or attending the practices or events of KoN BMCS, it is my stated intention to knowingly assume all risks involved in participating in or attending these events and practices, and release all Cities, all Park and Recreation Divisions, owners of event locations, KoN BMCS and their officers and agents from any responsibilities or liability for any injury, physical or emotional, that I may sustain while participating in or attending the KoN BMCS practices or events.  I fully understand and agree that the Hosts and their agents will not be held liable for any injuries, damages, or death caused by or resulting from negligence of the Hosts, which is caused in whole or in part by any of my acts, including negligent acts.

Contractually binding:

I agree for myself and my successors, that the above representations are contractually binding, and are not mere recitals, and that should I or my successors assert my claim in contravention of this Agreement, I or my successors shall be liable for the expense (including but not limited to, legal fees) incurred by the other party or parties.  No officer or agent has the authority to modify this agreement orally.  A waiver of any provisions of this Agreement shall not be construed as a modification of any other provision, or as consent to any other subsequent waiver of modification.

Optional Image Use:

By agreeing to this section, I give permission to KoN BMCS to use my image in KoN BMCS media within Grand Rapids, Michigan and the greater Belegarth community.  This use includes the display, distribution, publication, transmission, or other use of photographs, images, and/or videos taken of the undersigned for use in, but not limited to, printed media (brochures/newsletters/posters), videos and digital media.

Optional Medical Information Section:

Below you may list any medical information you feel is important for the officers of KoN to know. If you fill out this section please include any drugs, food, or environmental allergies, any anaphylactic reactions, physical or medical conditions (diabetes, knee or back problems, and other lasting illnesses/conditions), eyesight impairments (glasses/contacts) and any other medical information you feel is important.

I have fully read, understood, and agree to everything stated in this release form.

By selecting "I Agree" box you are providing your digital signature for the Belegarth Waiver listed above.