WCGH Oncology Walk Waiver/Photo Release

I, ____________________________________, have chosen to participate in the Oncology 5k Walk, Saturday, October 14, 2017 at Waldo County General Hospital, organized by Waldo County General Hospital (WCGH). I recognize that the program involves physical activity and I am participating of my own volition and will walk at a pace appropriate for my state of physical health.

If I am also an employee of WCGH, PBMC or another MaineHealth entity, I understand and agree that my participation in this program is voluntary, is in no way required or expected by my employer and is outside the scope of my employment.

I have been advised that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed. If I have chosen not to obtain a physician’s consent prior to participating in this activity, I hereby agree that I am doing so solely at my own risk. I understand that it is my sole responsibility to participate in exercises that are appropriate for the current status of my health and to ask my doctor if a particular activity is appropriate to my health status if I have any questions or concerns.

I understand that any exercise or fitness activity involves a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death. I am accepting such risks and volunteering to participate with full understanding of the risks involved. In consideration of my participation in this program, I, _______________________________, hereby waive and release WCGH, MaineHealth and any of its employees volunteering for or participating in this program, and their successors and assigns, from any and all claims, costs, liability and expense for any injury, loss or damage whether known, anticipated or unanticipated arising from my voluntary participation.

By participating in this event, I also grant WCGH permission to copyright and/or publish verbal and/or written testimonials and photographic portraits or pictures of me, or in which I may be included in whole or in part, or composite or distorted in character or form, in conjunction with my name and/or testimonial, through any media for art, advertising, trade or any other lawful purpose whatsoever in perpetuity. I hereby waive any right that I may have to receive compensation of any kind for the use of my testimonial or photograph.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND IT. I UNDERSTAND THAT IT CONTAINS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING CERTAIN RIGHTS I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST WALDO COUNTY GENERAL HEALTH OR MAINEHEALH OR ANY OF THEIR EMPLOYEES VOLUNTEERING FOR OR PARTICIPATING IN THIS PROGRAM. _________________________________________ (Participant Signature) _______________________________ (Date)