Fill and Sign the Accidental Injuries Form

Waiver and Release of Claims for Future Accidental Injuries or Death by Individual Applying to Rent a Bicycle (Includes Consent of Parent or Guardian of a Minor) Whereas, the undersigned ______________________ of ______________________ ____________________________________________ (street address, city, county, state, zip code) , wishes to rent a bicycle from ______________________ , Inc., a corporation organized and existing under the laws of the state of ______________, with its principal office located at ____________________________________________ (street address, city, county, state, zip code) , referred to herein as Company ; and Whereas, I acknowledge that cycling is an inherently dangerous sport in which I participate at my own risk; and Whereas, Company will not rent a bicycle to me unless I sign this waiver, release and assumption of risk agreement; and Whereas, it is my intention to ride any bicycle I rent from Company in and around the city of __________________________ (name of city and state), hereinafter referred to as City ; and Whereas, I acknowledge that City does not, will not, and has no duty to, insure or guarantee that I will not have an accident resulting in serious injury or death while renting or riding said bicycle; Now, therefore, the undersigned does hereby agree to, covenant to, and represent the following: A. I, on behalf of myself, my heirs, assignees and personal representatives, do release and forever discharge Company and City , their employees, officers, and agents (all of which are hereinafter jointly and severally referred to as Released Parties ) from any and all liability, claim, loss, cost or expense, arising directly or indirectly from, or attributable in any legal way to, any negligence, action or omission to act of Released Parties that results from my rental of said bicycle. B. I, on behalf of myself, my heirs, assignees and personal representatives, do hereby waive and promise not to sue on any such claims against Released Parties arising directly or indirectly from or attributable in any legal way to, any negligence, action or omission to act of Released Parties that results from my rental of said bicycle. C. I currently have no known physical or mental condition that would impair my capacity to safely use said bicycle as intended or expected except for (specify, and if none write “NONE”): ____________________________________________________________________ D. I hereby assume all risks associated with using this Bicycle and I do release the Released Parties for any injuries to me that may occur during my use of said Bicycle. I certify that the information on this document, as entered by me, is truthful. E. I, on behalf of myself, my heirs, assignees and personal representatives, agree to indemnify and save Released Parties harmless for any and all liability, claim, loss, cost or expense, arising directly or indirectly from, or attributable in any legal way to, my actions or any negligence, action or omission to act of Released Parties that results from my rental of said bicycle. WITNESS my signature on this the ____ day of ___________, 20____. ________________________ AGREEMENT AND CONSENT OF PARENT OR GUARDIAN OF MINOR I, as parent or guardian of the above applicant, represent to the Released Parties that the facts in this document concerning my child or ward are true. I give my permission for my child or ward to rent a bicycle from Company and further, in consideration of renting said bicycle to my child or ward, I agree individually and on behalf of my child or ward, to the terms of the above Waiver and Release. WITNESS my signature on this the ____ day of ___________, 20____. ________________________ Parent or Guardian Acknowledgment before Notary Public (form may vary by state)