RISK ACKNOWLEDGEMENT & DISCLAIMER
THIS IS AN IMPORTANT DOCUMENT: YOU MUST READ IT BEFORE SIGNING
(Name) I, …………………………wish to use a Segway for an activity (“the Activity”) organised by TrySegway (“The Company”) on the date of completion of this form and hereby declare that:
1. I am 18 years or older and weigh between 45kg and 120kg.
2. I agree that I will undertake the activity in accordance with the Safety Rules that I have received with this document together with the oral instructions and advice given to me by the instructors before undertaking the Activity.
3. I understand that a helmet is provided for my safety and I agree to wear the helmet and have it fastened at all times when operating the Segway.
4. I understand and acknowledge that operation of the Segway has a significant potential for serious injury and that it is necessary for me to maintain control of the Segway at all times to minimise this risk. I am voluntarily participating in this Activity with the knowledge of the dangers involved and I agree to accept any and all risks of loss, injury, damage or death.
5. I acknowledge that I am responsible for my own safety and that of any under 18 year old riders that I have signed responsibility for.
6. In the event of an accident or any damage, loss, injury or death I acknowledge that the Company, or its members and agents, will not be liable for any direct or indirect loss, damage, injury or death arising from or in connection with the Activity (except for death or personal injury caused by the Company’s negligence) and I waive all and any claims against the Company in this respect. I agree to indemnify, defend and hold harmless the Company and any of its members or agents, against any and all consequential claims made by any third party arising from such an event.
7. I agree immediately to cease operation of the Segway if I am concerned in any way about its operation.
8. I certify that to the best of my knowledge I do not have a medical condition which might have the effect of making it more likely that I be involved in an accident which could result in injury to me or others. To the best of my knowledge I am not pregnant.
9. I confirm that I am not under the adverse influence of drink or drugs.
E-mail:
Address:
Signature:
Date:
RISK ACKNOWLEDGEMENT & DISCLAIMER
by the legal guardian of 12 to 17 year old RIDERS
THIS IS AN IMPORTANT DOCUMENT: YOU MUST READ IT BEFORE SIGNING
(Name) I,………………………….am the parent or guardian of the child(ren) listed below who is/are aged from 12 to 17 years, and wish for that/ those child(ren) to participate in the Activities organised by the Company on the date of completion of this form.
I declare that:
1. I am the legal guardian of the child(ren) listed and I am responsible for the child (ren) in my care and undertake to ensure that he / she / they undertake(s) the Activity in accordance with this document and the Safety Rules that they received together will the oral instructions and advice given to me and him / her/ them by the instructors before undertaking the Activity.
2. I understand that the weight of the rider can affect the safe operation of the Segway PT and declare that all children listed weigh between 45kg and 117kg
3. I will keep the children under my supervision within full sight whilst on the activity and ensure that they travel at a speed at which they can comfortably control the Segway.
4. I understand that a helmet is provided for the rider’s safety and agree that it is my responsibility to ensure that any child(ren) that I am responsible for will wear the helmet and have it fastened at all times when operating the Segway.
5. I understand and acknowledge that operation of the Segway has a significant potential for serious injury and that it is necessary for the child(ren) to maintain control of the Segway at all times to minimise this risk.
6. I understand and acknowledge that the child(ren) that I am responsible for will be, at times, be undertaking the Activity without direct supervision from a responsible adult, save that provided by myself.
7. In the event of an accident or any damage, loss, injury or death involving the child(ren) listed below I acknowledge that the Company will not be liable for any direct or indirect consequential loss, damage, injury or death arising from or in connection with the Activities (except for death or personal injury caused by the Company’s negligence) and I waive all and any claims against the Company in this respect in respect of the child(ren) in my care.
8. I certify that the child(ren) do not have a medical condition which might have the effect of making it more likely that he/she/they be involved in an accident which could result in injury to him/her/themselves or others. (if in doubt please check with the child’s parent or guardian).
9. I agree immediately to ensure the cessation of operation of the Segway by any child(ren) in my care if I am, or they are concerned in any way about its operation.
NAMES OF PARTICIPANTS FROM 12 TO 17 YEARS OF AGE THAT I AM RESPONSIBLE FOR:
1
2
3
4
I acknowledge that I and the child(ren) in my care (if applicable) have received, read and understood the Safety Rules in relation to the Activity.
E-mail:
Address:
Signature:
Date:
All photographs taken by the Company during the Activity remain the property of the Company and may be used in promotional and advertising materials. Copies of photographs taken by TrySegway will be mailed to a nominated member of your group, using the e-mail provided above.