0926d Waivers and Release of Liability and Other Use Release,

OMB Number:
Respondent Burden: 20 minutes

WAIVER & RELEASE OF LIABILITY
AND OTHER USE RELEASE
NATIONAL VETERANS GOLDEN AGE GAMES

PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17,
Section 1710. VA may disclose the information that you put on this form as permitted by law. VA may make a "routine use"
disclosure of the information as outlined in the Privacy Act systems of records notices identified as 121VA19 “National Patient
Databases - VA”. Providing the requested information is voluntary.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor,
and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who must complete this application will average 20 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the forms.

In consideration of being allowed to participate in the
National Veterans Golden Age Games, related
events, and activities, (collectively the "Games"), I , the undersigned, acknowledge, appreciate, and agree that:
1. I, for myself and on behalf of my heirs, assigns, personal representatives, administrators, and next of kin,
HEREBY RELEASE, HOLD HARMLESS, COVENANT NOT TO SUE, AND FOREVER DISCHARGE the
United States Government; the Department of Veterans Affairs ("VA"); VCS; HHV; their officers, directors,
members, vendors, contractors, agents, and employees; and, any and all sponsoring agencies, sponsors,
advertisers, owners, and lessors of premises used to conduct the Games, related events and activities; and
officials, volunteers, and other participants of the Games, (hereinafter "RELEASEES"), from any and all
liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any and all injury,
disability, death, or loss or damage to person or property, whether arising from the negligence of any of the
RELEASEES, or otherwise, while participating in the Games.
2. The risk of injury from the activities involved in these Games is significant, including the potential for serious
bodily injury, including death, and property damage. I am fully aware of the risks and hazards associated with
participating in these Games and I voluntarily, without any inducement, elect to participate in the Games. I
KNOWINGLY AND VOLUNTARILY 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.
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 presence or participation, I will remove myself from
participating and bring such to the attention of the nearest official immediately.
4. I hereby consent to medical treatment in the case of emergency. I agree to assume full responsibility for
payment of any and all fees incurred as a result of such medical treatment.
IN CASE OF EMERGENCY, NOTIFY:

ADDRESS (Street, City, State and Zip Code)

NAME

TELEPHONE NUMBER

SIGNATURE (MANDATORY)

RELATIONSHIP

DATE SIGNED

NAME PLEASE PRINT (First, MI, Last)
VA FORM
APR 2010

0926d

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