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Print Version Minor's Release
Print Version Minor's Release
W.O.M.P.
Minors Assumption of Risk Acknowledgement
1 (618) 713-4346
Mike Wright: Owner
Name of Event: _______________________________________________________
4596 State Highway 149 Event Dates: ________________________________ Year: ___________________
Royalton IL 62983
I have obtained my parents consent to enter the premises and participate in the above event(s). I understand that I am assuming all
the risks if I get hurt or killed during the event(s) and I state the following.
1.
2.
3.
Both my parents and I believe I am qualified to participate in the event(s). I will inspect the premises and the equipment
and if, at any time I feel anything to be unsafe, I will immediately leave and refuse to participate further in the event(s).
I understand that the ACTIVITIES OCCURING ON THE PREMISES AND OF THE EVENT ARE VERY DANGEROUS and INVOLVE
RISK AND DANGERS OF MY BEING SERIOUSLY INJURED OR HURT, MY BEING PARALYZED OR KILLED.
I know that these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others
participating in any activity on the premises including any of the event(s), the rules of the event(s), the condition and layout
of the premises and equipment, or negligence of others, including those persons or entities or their affiliates and
subsidiaries responsible for conducting the event(s).
I HAVE READ THE ABOVE ASSUMPTION OF RISK ACKNOWLEGEMENT, UNDERSTAND WHAT I HAVE READ, & SIGN IT VOLUNTARILY
__________________________________________________________________________________________________________
SIGNATURE OF MINOR PARTICIPANT
PRINTED NAME OF PARTICIPANT
AGE
DATE
__________________________________________________________________________________________________________
SIGNATURE OF PARENT/GUARDIAN
PRINTED NAME OF PARENT/GUARDIAN
DATE
Signature: ________________________________________________
Date: _______________________________