Please sign and return this form

Coen’s Pond

KMA Racing Watercross Practice Area

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

Permit Holder Information:

PLEASE PRINT

Last Name:________________________________________

First Name:________________________________________ Date of Birth:___________________

Address: __________________________________________

City/State/Zip_____________________________,_____________________________,____________

Telephone:______________/__________/_____________

email:_________________________________

I, the above permit holder understand that I am risking injury and possible injury or death to myself and anyone whom I bring with me to this site. I also agree that I am responsible for myself, my spouse and my children I have with me and I hold any and all parties harmless to include, IWA Watercross, KMA Racing, Dale, Jean & Arthur Coen, Arlen & Vicki Peterson, Eric Peterson, any member of KMA Racing and any member or non member of IWA Watercross who is helping out, from any accidents or injuries involved directly or indirectly before, during or after this practice date. I also understand that the noise levels may hurt my or my children’s ears which could result in hearing loss.

List any Children who will be with you on site. Please Note that you a responsible for them.

NO children allowed to walk around unattended.

1._____________________________________________________2.________________________________

3._____________________________________________________4.________________________________

5._____________________________________________________6.________________________________

I have read and understand this release and waiver of liability, assumption of risk and indemnity agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and have signed it freely and voluntarily without any inducement, assurance or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Permit Holder Signature:____________________________________________________Date:___________

Parental Consent if Under 18 years old: Print Name _____________________________

Signature _______________________