Republic of the Philippines

Department of the Interior and Local Government

BUREAU OF JAIL MANAGEMENT AND PENOLOGY
REGIONAL OFFICE VI
2nd & 3rd Floor, Ignie’s Place, Brgy. Buhang, Jaro, Iloilo City
Tel No. (033) 503-4018
Email Address: rbjmp6@gmail.com Website: www.bjmpr6.com

ACCIDENT WAIVER AND RELEASE OF LIABILITY

I, _______________________________________, OF LEGAL AGE, HEREBY ASSUME ALL THE

RISK OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH THIS
PHYSICAL AGILITY TEST scheduled on __________________________________ at
__________________________
ILOILO SPORTS COMPLEX, MAGSAYSAY VILLAGE, LAPAZ, ILOILO CITY.
________________________________________________________________________

Also, I hereby manifest the following:

1. I, signify willingness to undergo the said Physical Test and that I understand
the difficult and risk involved in it.
2. I’m in good physical, mental and/or medical condition and I’m not suffering
from any diseases that may limit me to perform strenuous activities.
3. I acknowledge that this Accident Waiver and Release of Liability Form will
be used by the Training Committee of the activity in which I may
participate, and that it will govern my actions and responsibilities at said
activity. I agree that all staff or authorized agents may, in their sole
discretion, determine if it unsafe for me or others for my participation to
continue remove me from the premises by any lawful means.

I WAIVE, RELEASE, AND DISCHARGE from any liability, including but not limited to,
liability arising from negligence of fault of the entities or persons released, for my death,
disability, personal injury, property damage, property theft, or actions of any kind which
may hereafter occur to me.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND ITS
CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT
AND I SIGN IT OF MY OWN FREE WILL.

___________________________________
Participant’s Signature over printed name
(Please print legibly)

___________________ ___________________
Age Date

Witnessed by: Witnessed by:

_____________________________ ________________________________
Signature over printed name Signature over printed name

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