Release Form KDCsports.com
PRINT THIS FORM FROM OUR WEB SITE AND SIGN IN APPROPRIATE LOCATIONS.
39 McLelland Drive
Courtice, Ontario, L1E 1Z9
Office- 905-436-9013
E-mail- dburnham@kdcsports.com
Please print the following information carefully.
Participant Name (first) ______________________ (Last) ________________________________
Street/Apt No ____________________________________________________________
Town/City ________________________________
Province/State _____________________________ Postal Code/Zip ___________
You are required to sign this form to Participate in filming of a Skills Video
Medical Insurance/ OHIP NUMBER _____________________________
KDCsports.com Standard Release Form
As used in this document, the terms “I,” “my,” and “you,” refer to the undersigned or his or her legal or natural guardian who has signed this document below on behalf of his or her legal or natural ward or child.
As used in this document, the term KDCsports.com refers to David Burnham Sole owner of KDCsports.com.
I recognize and acknowledge that_______________, is inherently a hazardous activity that could result in bodily injury. I hereby release KDCsports.com from all actions, causes of action, damages, claims, or demands that I, my heirs, executors, administrators, successors, or assigns may have, at any time now or in the future, against KDCsports.com for all personal injuries known or unknown that I have or may incur by participating in _______________ video taping sessions with KDCsports.com;
I recognize and acknowledge that KDCsports.com makes no promise, representation, or guarantee of any kind whatsoever; without limiting the foregoing, I recognize and acknowledge that KDCsports.com makes no promise, representation, or guarantee concerning the following: my current or future success at the game of _______________ or any aspect of the game of _______________ ; my current or future placement on any sports/athletic/recreational team or organization; my chances of receiving a scholarship of any kind whatsoever.
I recognize and acknowledge that any expression or comment that KDCsports.com has made or may have made, now or in the future, is an expression of opinion, only, and in no way constitutes a representation, guarantee, or promise of any kind. I am not relying upon any such expression or comment;
I authorize KDCsports.com to consent to any X-ray examination, anesthetic, ethical or surgical diagnosis, treatment, or procedure, and hospital care, to be rendered to me on the advice of any physician or surgeon licensed to practice in the province of Ontario, and to consent to any X-ray examination, anesthetic, dental or surgical diagnosis, treatment, or procedure to be rendered by a dentist or dental surgeon licensed to practice in the province of Ontario;
I authorize KDCsports.com to make available such information as contact information, academic information and athletic information to interested parties for the purposes of advancing me in my sport. I accept the fact that KDCsports.com and KDCsports.com web master will be in possession of this information.
This document shall be governed, construed, and interpreted in all respects in accordance with the laws of the province of Ontario. The Provincial Court of the Province of Ontario, shall have jurisdiction to hear and determine any matter arising therefrom. I hereby expressly submit and consent in advance to such jurisdiction in any action or proceeding commenced by the other in such court;
This document contains the entire agreement of the parties. No other document, statement, or promise made on or before the effective date of this document will be binding on the parties. If any provision of this document is held in whole or in part to be unenforceable for any reason, the remainder of that provision and of the entire document will be severable and remain in effect. This document may be modified by subsequent agreement of the parties only by an document in writing signed by both of them;
This document shall be effective when signed by you, and delivered to and accepted by the home office of KDCsports.com.
READ, UNDERSTOOD, AND ACCEPTED:
If you are signing on behalf of another, you represent that you are the legal or nature guardian of the child or ward on behalf of whom you are signing this document and that you have the legal authority to sign this document on behalf of said individual; you agree to indemnify and hold KDCsports.com harmless from any and all actions, causes of action, damages, claims, or demands that may arise from or as a result of KDCsports.com reliance on such representation.
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Signature of parent or legal guardian
__________________________________________________________________________
Print Name
___________________________
Date:
Submit this signed form and with a Cheque made payable to David Burnham for 50 percent payment of selected package.
Mail to:
David Burnham
39 McLellan Drive
Courtice, Ontario
L1E 1Z9