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Participant’s (i.e. Student’s) Name (PLEASE PRINT):

Activity: Orchard United Methodist Church – Auction Climbing Party.

DESCRIPTION OF THE ACTIVITY AND DATE(S): On Saturday, February 24, 2018,
an Auction Climbing Party will take place in Detroit Country Day School’s Climbing
Wall in Room 174. This is not a DCDS sponsored or affiliated event. DCDS Climbing
Team Coach Ross Arseneau will organize and supervise the event. Participants should
be in good general health and be capable of participating in the various climbing

 BEHAVIOR DURING ACTIVITY: As a parent or legal guardian, I remain responsible for

the actions and conduct of my child while attending or participating in the Activity described
above. The Activity requires cooperation and safe behavior by my child (and me) and I
understand that we (my child and I) are required to abide by DCDS policies and code of
conduct during the Activity.
 ACCURATE INFORMATION: I affirm that the medical and emergency contact information
that I provided in connection with my child’s participation in the Activity (or as previously
provided to the school) is accurate and complete, and that failure to disclose necessary
information could affect my child’s safety, as well as other students/participants. In the event of
a medical emergency, I authorize DCDS and any emergency medical professionals to seek and
obtain medical treatment for my child as may be deemed necessary, including but not limited to,
transporting my child to a medical facility.


In consideration of participation in any way in the Activity, I, for myself, my heirs, personal
representatives or assigns, hereby release, waive, discharge, and covenant not to sue DCDS, its
officers, employees, directors, trustees, donors, independent contractors, volunteers, and agents from
liability from any and all claims including the ordinary negligence of DCDS its officers,
trustees, donors, directors, employees, independent contractors, volunteers, and agents,
resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but
not limited to, participation in The Activity.

Participation in The Activity carries with it certain known and unknown inherent risks, dangers, or
hazards that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary
from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and
sprains and 2) major injuries such as eye injury or loss of sight, soft tissue damage, joint or back
injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis, stroke, heart
attack, and death. The risk of falling or serious injury from falls, ropes or muscle injuries is possible.
This Activity also includes risks associated with travel to and from location(s) during the Activity,
including transportation provided by commercial, private, and/or public motor vehicles.


INDEMNIFICATION AND HOLD HARMLESS: I also agree to indemnify and hold DCDS
harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities,
including attorney’s fees brought as a result of my involvement in The Activity and to reimburse them
for any such expenses incurred.

ACKNOWLEDGMENT OF UNDERSTANDING: I expressly agree that this waiver and

assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of
the State of Michigan. I also expressly agree that if any portion of this agreement is held invalid, the
remaining portions shall continue in full legal force and effect. This agreement cannot be modified
unless in a writing signed by the Headmaster and me. This agreement supersedes any other agreements
or promises, oral or written, regarding its subject matter.

I have read all of the above paragraphs and I know, understand, and appreciate these and other risks
that are inherent in The Activity. I voluntarily allow my child to participate in the Activity under these
conditions. I fully understand and agree to the terms of this waiver of liability, assumption of
risk, and indemnity agreement, and understand that I am giving up substantial rights,
including my right to sue. I acknowledge that I am signing this agreement freely and voluntarily
and intend my signature to be a full release of liability to the greatest extent allowed by law

To be completed by Parent/Guardian of Minor Participant:

__________________________ ____________ ___________________

Signature Date

__________________________ ____________ __________________________

Name of Parent/Guardian of Minor Contact email and phone number

To be signed by Student/Participant if 18 or older

__________________________ _____________ __________________________

Signature Date