Page 3 of 3
Example of Including the State of North Carolina and the North Carolina Department of
Transportation in Release Waivers
*** Only required if not submitting a certificate of liability insurance ***
AGREEMENT TO PARTICIPATE RELEASE WAIVER
In consideration of being allowed to participate in any way in [Organization Name] related events and activities; the
undersigned acknowledges, appreciates and agrees that:
1. The risk of injury from the activities involved in [Event Name] is significant, including the potential for
permanent paralysis and death; and,
2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence
of the releasees or others, and assume full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If,
however, I observe any unusual significant hazard during my participation, I will remove myself from
participation and bring such to the attention of the nearest [Organization Name] representative; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release
and hold harmless [Organization Name], their officers, officials, agents and/or employees, volunteers, other
participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises
used to conduct the event.
5. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby
release and hold harmless the State of North Carolina, the North Carolina Department of
Transportation, [County Name] County, [Municipality Name, if applicable], their officers, officials,
agents and/or employees, volunteers.
6. I grant to [Organization Name] my permission to use without charge any and all photographs, video
reproductions or other like kinds of image productions taken during the event.
7. I understand that [Event Name] and its staff are not responsible for the loss, theft, or any damages to
personal property which includes, but is not limited to bicycles, vehicles, tents, trailers, luggage, etc.
8. I understand that I can be removed from the ride at any time for any reason with no refund.
I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I
have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.
_________________________________ __________________________________ ______________
Name Signature Date