Advanced Strategies Adventures, Inc.

7703 Kirkville Road, Kirkville, NY 13082

Waiver and Release of Liability Form & Medical Authorization

PARTICIPANT’S NAME:_________________________________________AGE_________BIRTHDATE:___________

ADDRESS:_________________________________________________________________________________________

PARENT/GUARDIAN:_________________________________________________PHONE:_______________________

EMERGENCYCONTACT/RELATIONSHIP:______________________________________PHONE:________________

DESCRIPTION OF ACTIVITY:

I have read this form carefully, and am aware that by agreeing to this form and registering the participant/minor child//ward/charge and in consideration of ADVANCED STRATEGIES ADVENTURES, INC. allowing the above named to participate the activities listed with ADVANCED STRATEGIES ADVENTURES, INC., that I am WAIVING and RELEASING all claims for myself and my participant/minor child/ward/charge arising out of such registration and participation in the activities run by and use of facilities owned by ADVANCED STRATEGIES ADVENTURES, INC.. In further consideration for such use, I hereby agree as follows:

ACKNOWLEDGEMENT AND ASSUMPTION OF RISK OF INJURY AND LOSS:

I understand and acknowledge that participation in these activities and use of facilities and grounds involve inherent risks of injury, including the potential for property loss, bodily injury, permanent disability and death. I further acknowledge that that participation in these activities and use of facilities and grounds owned by ADVANCED STRATEGIES ADVENTURES, INC. could result in injury, disability or death unrelated to participant’s direct actions.

I knowingly, freely, and voluntarily assume all such risks whether known or unknown, even if such risk is the result of the negligence of any the employees, owners, officers, directors, agents, servants, volunteers, representatives, supervisors, successors and assigns of ADVANCED STRATEGIES ADVENTURES, INC.. I further assume full responsibility for the participant’s participation.

WAIVER OF AND RELEASE OF CLAIMS:

I hereby agree to, and do, waive, release and relinquish all claims, demands, rights of action, damages, liabilities and controversies of every kind, known and unknown, present and future, that I, or my participant/ minor child/ward/charge on whose behalf I am signing may have against the ADVANCED STRATEGIES ADVENTURES, INC. and their employees, owners, officers, directors, agents, servants, volunteers, representatives, supervisors, insurers, related or affiliated individuals or entities,successors and assigns arising out of, connected with, or in any way related to the participation in the activities run by and/or use of related facilities owned by ADVANCED STRATEGIES ADVENTURES, INC. or my participant’s/ minor child/ward/ charge's use therein.

INDEMNITY AND DEFENSE:

I hereby further agree to indemnity and hold harmless and defend ADVANCED STRATEGIES ADVENTURES, INC. and their employees, owners, officers, directors, agents, servants, volunteers, representatives, supervisors, insurers, related or affiliated individuals or entities,successors and assigns from any and all claims, lawsuits, demands, damages, liabilities, losses and expenses, including attorney's fees and administrative expenses, of every kind, known and unknown, present and future, arising out of, connected with, or in any way related to my or my participant/ minor child/ward/ charge's participation in the activities run by and/or use of related facilities owned by ADVANCED STRATEGIES ADVENTURES, INC..

EMERGENCY CARE MEDICAL AUTHORIZATION / INDEMNIFICATION:

In the event of an accident, medical emergency or illness,in which I cannot be contacted immediately, I authorize ADVANCED STRATEGIES ADVENTURES, INC. and their employees, owners, officers, directors, agents, servants, volunteers, representatives, supervisors, successors and assigns to secure, from any licensed hospital, physician and/or other medical/dental personnel, any and all treatment deemed reasonable and necessary for my or my participant/minor child/ward/charge’s immediate care and agree that ADVANCED STRATEGIES ADVENTURES, INC. assumes no financial obligation or liability. I will be responsible for payment for any and all such treatment rendered. Please have your signature witnessed by an adult different from the person you are making responsible for your child/ward/charge.

I certify that I am the parent/legal guardian/power of attorney or have the legal authority to sign on behalf of any minor/ward/charge being registered herein. I am authorized to enter into this agreement and that I do so freely and voluntarily for myself, my heirs, personal representatives and their successors and assigns, and/or my participant/minor child/ward/charge  identified in the registration portion of this document and his/her heirs, personal representatives and their successors and assigns.

I have read and fully understand the above Waiver and Release of Liability Form & Medical Authorization and execute it of my own free will and without any reservation whatsoever.

I acknowledge that by accepting the terms of this Waiver and Release of Liability Form & Medical Authorization that I am entering a legally binding and enforceable agreement.

Participant/Parent/Legal Guardian Signature: ______________________________________________________________

Address:____________________________________________________________________Phone:__________________

Witness:___________________________________________________________________ Date:___________________