TRI-STATE GROTTO OF THE NATIONAL SPELEOLOGICAL SOCIETY

WAIVER OF RESPONSIBILITY FORM

 

AS A CONDITION FOR PARTICIPATING IN A CAVE TRIP WITH THE TRI-STATE GROTTO, I CERTIFY I AM IN GOOD HEALTH.  I AM AWARE THAT AN EXPEDITION IS INFLUENNCED BY CONDITIONS AND FORCES OF NATURE AND THAT SAID EXPEDITION INCLUDES RISKS AND DANGERS.  I ASSUME PERSONAL RESPONSIBILITY FOR THE RISKS AND DANGERS TO MY PERSONAL SAFETY AND FOR LOSS OF OR DAMAGE TO MY PROPETY AND RELEASE AND AGREE TO INDEMNIFY AND HOLD HARMLESS TRI-STATE GROTTO, THE NATIONAL SPELEOLOGICLAL SOCIETY, THE OWNERS OF ____Baker Quarry__FROM ACTIONS RELATED TO THESE RISKS AND DANGERS INCLUDING NEGLIGENCE.  THESE TERMS SHALL SERVE AS A RELEASE AND ASSUMPTION OF RISK FOR MY HEIRS, ALL MEMBERS OF MY FAMILY AND FOR ANY MINOR ACCOMPANYING ME.  SAID RELEASE SHALL INCLUDE ALL RIGHTS TO USE PHOTOGRAPHS AND VIDEOS TAKEN RELATIVE TO SAID EXPEDITION.  I FURTHER AGREE NEITHER TO VANDALIZE, LITTER, NOR DISTURB THE CAVE OR THE LAND AROUND IT (INCLUDING ROADS AND FENCES).  NOR WILL I PERMIT OTHERS TO DO SO.

PERMISSION IS HERBY GRANTED FOR THE TRIP LEADER TO AUTHORIZE FIRST-AID, AS WELL AS SUCH MEDICAL OR SURGICAL TREATMENT AS MAY BE DEEMED APPROPRIATE BY DULY LICENSED PHYSICIAN OR HOSPITAL FOR ANY ILLNESS OR INJURY INCURRED OR SUSTAINED WHILE ENGAGED IN CAVING ACTIVITIES.  THIS AUTHORIZATION SHALL BE APPLICABLE FROM THE TIME OF DEPARTURE TO THE TIME OF RETURN.

THE INTERPRATATION OF THE TERMS IN THIS AUTHORIZATION SHALL BE ENTIRELY AT THE DISCRETION OF THE AFOREMENTIONED OFFICIALS.

INSURANCE IS NOT PROVIDED BY THE GROTTO, ULTIMATE RESPONSIBILITY AND PAYMENT FOR SUCH SERVICES SHALL REST WITH THE PARTICIPANT AND/OR PARENT.

 

INSURANCE COMPANY NAME: ________________________________________________

POLICY NUMBER: ____________________________________________________________

I HEREBY CERTIFY THAT I AM ________ YEARS OF AGE AND I HAVE READ THIS RELEASE AND ASSUMPTION OF RISK AND I UNDERSTAND THE SAME.

 

PARTICIPANT: _______________________________DATE: _________________________

I, THE UNDERSIGNED, DO HEREBY CERTIFY THAT I AM THE PARENT AND LEGAL GUARDIAN OF THE ABOVE-NAMED PARTICIPANT AND I GIVE MY CONCENT IN SAID EXPEDITION.  I HEREBY AGREE TO AND ACKNOWLEDGE THAT I AM BOUND BY THE ABOVE RELEASE AND ASSUMPTION OF RISK, AND THAT I HAVE READ AND UNDERSTAND THE SAME.

 

PARENT/GUARDIAN: ______________________________________  DATE: ___________

ADDRESS: __________________________________________________________________

EMERGENCY TELEPHONE NUMBER: __________________________________________