EMERGENCY AUTHORIZATION: I, the undersigned parent or legal
guardian of the above minor, hereby
authorize Quiksilver, Inc. and its affiliates
(“Quiksilver”) and/or the above-identified Emergency
Contact/Chaperone to act as my agents
in the capacity of activity supervisors and vehicle drivers, and
to consent to medical, surgical or
dental examination and /or treatment.
DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I, the undersigned
parent or legal guardian of the above
minor, for myself and on behalf of the above minor, our heirs,
assigns and next of kin (“I”), acknowledge that
Quiksilver does not operate the Quiksilver /Roxy Surf
Camp (the “Camp”) and participation in the Camp (including
photo-shoots, surf trips, surf instruction, and other
surf events that Quiksilver may sponsor or in which Quiksilver
athletes may compete) involves travel, participation in
inherently dangerous activities (often in adverse conditions),
physical contact and risk of severe, permanent physical injury
including brain damage, nerve and spinal cord injury,
paralysis and death. For myself, and on behalf of the
above minor, our heirs, assigns and next of kin, we willingly
and voluntarily accept and assume all
such risk. In consideration of
accepting and permitting the voluntary participation of the
above-named participant in the Camp, I
hereby release, discharge and agree to hold harmless Quiksilver,
its employees, volunteers, officials, sponsors and
other representatives from any and all damages, claims,
demands, costs, expenses and compensation arising out of or
in any way related to any injury, physical or otherwise, or
other damage that may result to said participant, or the
property of said participant, in connection with the
Camp.ACKNOWLEDGEMENT AND CONSENT: I acknowledge that
Quiksilver may compile and use the name,
likeness, recorded voice, addresses, photographs,
biographical sketch, film and videos of the named individual in
advertising, marketing, product, packaging or other use,
without compensation and without restriction as to duration,
geography, media or frequency. I consent to such uses and
hereby waive all rights to compensation.
I HAVE READ THE ABOVE EMERGENCY AUTHORIZATION,
DISCLAIMER, ASSUMPTION OF RISK AND
WAIVER, AND ACKNOWLEDGEMENT AND CONSENT PROVISIONS, FULLY
UNDERSTAND THE TERMS OF EACH,
UNDERSTAND THAT I AND THE ABOVE PARTICIPANT HAVE GIVEN UP
SUBSTANTIAL RIGHTS BY MY SIGNING THIS FORM AND AGREEING TO THESE
TERMS, AND I
Parent Signature:____________________________________________
Date:__________________
I,_________________________ [Name], hereby acknowledge that I
will be participating in a Quiksilver /Roxy sponsored surf (the
"Camp"). I am 18 years of age or older
and I acknowledge that I have read and understand the terms of
this release. In consideration of the
right to participate in the Camp, which I acknowledge is good,
valuable and sufficient consideration,
I hereby agree as follows:
1. I acknowledge that Quiksilver, Inc. and its officers,
directors, shareholders, affiliated companies, agents, and
employees of each of them (collectively, “Quiksilver”)
and any other sponsors or co-sponsors, promoters and host(s)
(“Other Releasees”) of the Camp do not operate the Camp,
and have not and do not assume any liability for any
injury, damage or loss of any nature whatsoever which may
occur as a result of any reason, either during the Camp,
while traveling to or from the Camp, or while lodging for the
Camp.
2. I acknowledge that I may be participating in dangerous
activities at the Camp, including the inherently dangerous
surf, skate or snow activities contemplated by the Camp.
I understand that the risk of injury from the activities
involved in the Camp is significant, including the
potential for permanent paralysis and death, and while
particular rules, equipment, and
personal discipline may reduce this risk, the risk of serious
injury does exist.
3. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known
and unknown, EVEN IF ARISING FROM THE
NEGLIGENCE OF QUIKSILVER, THE OTHER RELEASEES, or others, and
assume full responsibility for my
participation, and I willingly agree to comply with any stated
and customary terms and conditions for
participation. If, however, I observe any unusual significant
hazard during my presence at the Camp
or involved with my participation, I will remove myself from
participation and bring such to the attention of the
nearest official immediately.
4. I hereby release Quiksilver and the Other Releasees from
any and all claims, demands, causes of action, losses,
expenses, costs and liability of any nature whatsoever
which I may hereafter have against any of them arising out of
or in connection with the Camp.
5. I grant to Quiksilver the right to, and acknowledge that
Quiksilver may, use my name, likeness, portrait, recorded
voice, addresses, photographs, biographical sketch, film
and videos of me in advertising, marketing, product,
packaging or other use, without compensation and without
restriction as to duration, geography, media or frequency.
6. If I become incapacitated and require emergency medical
treatment, I hereby consent to medical or dental
examination and treatment.
If you are under the age of 18, your parent or legal guardian
must sign the Minor Release Form. You will not be
allowed to participate in this Camp without your parent's
or legal guardian's signature.
Participant Name __________________________ Participant
Signature _________________________________
