MY URGENT CARE PATIENT REGISTRATION FORM urgentcare12
My Urgent Care is a privately-owned, non-hospital affiliated Urgent Care system in Northern Virginia. We've been leaders in urgent care services and walk in clinics for over twenty-five years.
Whether you need immunizations, physicals, have aches, flu, minor injuries or need any urgent care services for the entire family, My Urgent Care offers walk in convenience and same day doctor visits. Just walk in to any of our medical clinics. We have two locations are open till late and serve Fairfax, Alexandria, Arlington, Prince William and Stafford Counties.
Join the City of Dayton's Department of Recreation and Youth Services at Linder Family Tennis Center for a day of fun, fitness and education! Kids 12-18 will enjoy tennis instruction, fun activities, lunch, t-shirt, gift back and Center Court Ticket...all for FREE!
Affidavit of Eligibility and Release Associated with the Degas/Cassatt Like t...Booz Allen Hamilton
This is the Affidavit of Eligibility and Release Associated with Booz Allen Hamilton's Degas/Cassatt Like to Win Contest. For complete contest rules, visit: slidesha.re/1oRIFEd.
Self declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the student
MY URGENT CARE PATIENT REGISTRATION FORM urgentcare12
My Urgent Care is a privately-owned, non-hospital affiliated Urgent Care system in Northern Virginia. We've been leaders in urgent care services and walk in clinics for over twenty-five years.
Whether you need immunizations, physicals, have aches, flu, minor injuries or need any urgent care services for the entire family, My Urgent Care offers walk in convenience and same day doctor visits. Just walk in to any of our medical clinics. We have two locations are open till late and serve Fairfax, Alexandria, Arlington, Prince William and Stafford Counties.
Join the City of Dayton's Department of Recreation and Youth Services at Linder Family Tennis Center for a day of fun, fitness and education! Kids 12-18 will enjoy tennis instruction, fun activities, lunch, t-shirt, gift back and Center Court Ticket...all for FREE!
Affidavit of Eligibility and Release Associated with the Degas/Cassatt Like t...Booz Allen Hamilton
This is the Affidavit of Eligibility and Release Associated with Booz Allen Hamilton's Degas/Cassatt Like to Win Contest. For complete contest rules, visit: slidesha.re/1oRIFEd.
Self declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the studentSelf declaration by the student
If you aren't going to the sign-up meeting, you have to fill this out, along with the sign-up sheet and send these things with your money to the meeting!
1. WAIVER AND RELEASE OF LIABILITY
UNDER KENTUCKY LAW, A FARM ANIMAL ACTIVITY SPONSOR, FARM
ANIMAL PROFESSIONAL, OR OTHER PERSON DOES NOT HAVE THE
DUTY TO ELIMINATE ALL RISKS OF INJURY OF PARTICIPATION IN
FARM ANIMAL ACTIVITIES. THRE ARE INHERENT RISKS OF INJURY
THAT YOU VOLUNTARILY ACCEPT IF YOU PARTICIPATE IN FARM
ANIMAL ACTIVITIES. KRS 247.4027
In consideration of my participation, I, on behalf of myself, and my estate, heirs, personal
representatives, executors, administrators, and assigns, do release and discharge and
covenant not to sue Murray State University; Murray State University Board of Regents;
any of their regents, employees, instructors, or agents, and any and all other persons or
entities whatsoever [herein refereed to as the “Released Parties”] from and with respect to
any and all present and future claims, of whatever nature or kind, regardless of the basis
therefore and including but not limited to any claim based upon any wrong doing or
negligence, of whatever nature or kind including ordinary and/or gross negligence, on the
part of the Released Parties, or any of them, and including but not limited to any claim
for injury to property of injury or death to person. Arising from or related, in any manner,
to participants involvement in the Equestrian Classes, or to any activities, including
instruction and traveling to or from events, related to any manner thereto. [Collectively
referred to as the “Released Claims”]
Further, I am aware that horse riding is a vigorous sport involving severe cardiovascular
stress in violent physical contact. I understand that it involves certain risks including but
not limited to, death, serious neck and spinal injuries resulting in complete or partial
paralysis, brain damage, and serious injury to virtually all bones, joints, muscles, and
internal organs and that equipment provided for the participant’s protection may be
inadequate to prevent serious injury. I further understand that horse riding involves a
particularly high risk or head and neck injury. In addition I understand that participation
in horse riding involves activities incidental thereto, including but not limited to, travel to
and from the site of the activity, participation at sites that may be remote from available
medical assistants, and the possible reckless conduct of other participants. I am
voluntarily agreeing to participate in this activity with knowledge of the danger involved
and hereby agree on my behalf to accept any and all risks of property damage, personal
injury, or death. A helmet should be worn by the undersigned at all times while riding a
horse on above property. In the event of a helmet is not worn the undersigned assumes
full responsibility for any injuries incurred.
I, on behalf of myself, and my estate heirs, personal representatives, executors,
administrators, and assigns, further agree to indemnity and hold harmless the Released
Parties, and each of them, in the event any claim is made against them or/and of them,
related in any manner or arising directly or indirectly from the Released Claims, or any of
them or the effects thereof even if it is alleged or proven that any such claims arise from
2. negligence, including gross negligence, or wrong doing on the part of the Released
Parties, or any of them.
I understand that this waiver is intended to be as broad and inclusive as permitted by the
laws of Kentucky and agree that if any portion is held invalid, the remainder of the
waiver will continue in full legal force and effect.
I affirm that I am of legal age and am freely signing this agreement. I have read this form
in fully understand that by signing this form, I, on behalf of the participant and myself are
giving up legal rights and/or remedies which may be available to me and the participant
against the Released Party.
(Name of Participant)
(Date)
(Signature of Parent or Guardian)
(Date)
(Signature of Parent or Guardian if Participant is under 18)
(Date)
State of ___________________________
County of _________________________
The forgoing Waiver and Release of Liability was executed before the undersigned
Notary Public by
___________________________and_______________________to his/her act and deed,
on this ___________day of_____________, 20____
____________________, My commission expires_______________
Notary Public
(affix Notary Seal)
![WAIVER AND RELEASE OF LIABILITY
UNDER KENTUCKY LAW, A FARM ANIMAL ACTIVITY SPONSOR, FARM
ANIMAL PROFESSIONAL, OR OTHER PERSON DOES NOT HAVE THE
DUTY TO ELIMINATE ALL RISKS OF INJURY OF PARTICIPATION IN
FARM ANIMAL ACTIVITIES. THRE ARE INHERENT RISKS OF INJURY
THAT YOU VOLUNTARILY ACCEPT IF YOU PARTICIPATE IN FARM
ANIMAL ACTIVITIES. KRS 247.4027
In consideration of my participation, I, on behalf of myself, and my estate, heirs, personal
representatives, executors, administrators, and assigns, do release and discharge and
covenant not to sue Murray State University; Murray State University Board of Regents;
any of their regents, employees, instructors, or agents, and any and all other persons or
entities whatsoever [herein refereed to as the “Released Parties”] from and with respect to
any and all present and future claims, of whatever nature or kind, regardless of the basis
therefore and including but not limited to any claim based upon any wrong doing or
negligence, of whatever nature or kind including ordinary and/or gross negligence, on the
part of the Released Parties, or any of them, and including but not limited to any claim
for injury to property of injury or death to person. Arising from or related, in any manner,
to participants involvement in the Equestrian Classes, or to any activities, including
instruction and traveling to or from events, related to any manner thereto. [Collectively
referred to as the “Released Claims”]
Further, I am aware that horse riding is a vigorous sport involving severe cardiovascular
stress in violent physical contact. I understand that it involves certain risks including but
not limited to, death, serious neck and spinal injuries resulting in complete or partial
paralysis, brain damage, and serious injury to virtually all bones, joints, muscles, and
internal organs and that equipment provided for the participant’s protection may be
inadequate to prevent serious injury. I further understand that horse riding involves a
particularly high risk or head and neck injury. In addition I understand that participation
in horse riding involves activities incidental thereto, including but not limited to, travel to
and from the site of the activity, participation at sites that may be remote from available
medical assistants, and the possible reckless conduct of other participants. I am
voluntarily agreeing to participate in this activity with knowledge of the danger involved
and hereby agree on my behalf to accept any and all risks of property damage, personal
injury, or death. A helmet should be worn by the undersigned at all times while riding a
horse on above property. In the event of a helmet is not worn the undersigned assumes
full responsibility for any injuries incurred.
I, on behalf of myself, and my estate heirs, personal representatives, executors,
administrators, and assigns, further agree to indemnity and hold harmless the Released
Parties, and each of them, in the event any claim is made against them or/and of them,
related in any manner or arising directly or indirectly from the Released Claims, or any of
them or the effects thereof even if it is alleged or proven that any such claims arise from](https://image.slidesharecdn.com/waiverandreleaseofliability-horsecontest-131211195832-phpapp02/85/Waiver-and-release_of_liability-_horse_contest-1-320.jpg)
