ADW ADULT LIABILITY WAIVER
RELEASE OF LIABILITY/MEDICAL RELEASE
(INCLUDING HIGH-RISK AND ADVENTURE ACTIVITIES)
Southern Maryland ROOTS Pilgrimage, September 24, 2022
1
I, _________________________, agree on behalf of myself, my heirs, assigns, executors, and personal
Full Name
representatives, to hold harmless and defend Our Lady of the Wayside, Holy Angels, Sacred Heart, St. Francis
Xavier Catholic Parishes, and the Archdiocese of Washington, its officers, directors, agents, employees, and
representatives (“Archdiocese”) from any and all liability for illness, injury or death arising from or in connection
with my participation in this activity or trip. I understand that this activity/event may involve high-risk activities,
with an increased risk of personal injury. I further understand that a separate, location-specific release and
liability form(s) (“Location-Specific Release”) may be required by the third-party provider(s) of the high-risk
activities (“Third-Party Provider”). I agree that it is my obligation to read the Location-Specific Release and
carefully consider the risks involved before signing.
W
ith appreciation of the dangers and risks associated with this activity/event and all related activities, I hereby
fully and completely release and waive any and all claims, including—but not limited to—those for personal
injury, death, or loss, that may arise against the Archdiocese of Washington and I hereby further agree that the
full scope of the Location-Specific Release’s waiver and release language shall also encompass any potential
claims against the Archdiocese of Washington related to this activity/event, such that the Archdiocese of
Washington is released from any and all claims at least to the same extent as the Third-Party Provider. I
hereby fully and completely release and waive any claims against the Archdiocese relating to and/or arising out
of the activity/event, to the fullest extent allowed by law.
I
acknowledge that my participation in the activity or trip is voluntary. I understand further that as a volunteer, I
am not covered by any type of workers compensation benefits or protection.
In the event that I should require medical treatment and I am not able to communicate my desires to attending
physicians or other medical personnel, I give permission for the necessary emergency treatment to be
administered. Please advise the doctors that I have the following allergies:
______________________
__________________________________________________________________
I
n case of an emergency and for permission for treatment beyond emergency procedures, please contact:
N
ame: _________________________________________________________
Relationship to me: _________________________ _____________________
Daytime Phone: _____________________ Cell: _______________________
Health Insurance Carrier: ___________________________________________
Insurance ID Number: ____________________________________________
Insurance Policy Number: _________________________________________
_______________________________ __________________
Signature Date
_______________________________
Print name
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signature
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