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Who Is This For?(Required)

Name of Adult(Required)

First Last

Parent or Guardian Name(Required)

First Last

How Many Minors?(Required)

Minor 1 Name(Required)

First Last

Minor 2 Name(Required)

First Last

Minor 3 Name(Required)

First Last

Minor 4 Name(Required)

First Last

Minor 5 Name(Required)

First Last

Minor 6 Name(Required)

First Last

Minor 7 Name(Required)

First Last

Minor 8 Name(Required)

First Last

Minor 9 Name(Required)

First Last

Minor 10 Name(Required)

First Last

Emergency Contact Name(Required)

First Last

Emergency Contact Phone Number(Required)

Consent(Required)

I Consent

I, Participant, certify that I am over the age of 18 and that, in consideration of being afforded the opportunity to participate in the below referenced Event, do knowingly, freely, and voluntarily hereby release and forever remise, release, acquit, discharge and forever hold harmless the DEPARTMENT OF ENVIRONMENTAL PROTECTION (“DEPARTMENT”), the BOARD OF TRUSTEES OF THE INTERNAL IMPROVEMENT TRUST FUND (“BOARD OF TRUSTEES”), the Wekiva Wild and Scenic River System Management Committee, and the STATE OF FLORIDA, and their employees, agents, and contractors, from all manner of actions, causes of action, suits, debts, dues, sums of money, covenants, contracts, liability, judgments, executions, claims, costs, attorney’s fees, demands, damages, and liabilities, whatsoever, in law, equity, or otherwise, that Participant or Participant’s heirs, executors, administrators, personal representatives, agents, successors or assigns have or may have against the DEPARTMENT, the BOARD OF TRUSTEES or the STATE OF FLORIDA and their employees, agents and contractors, arising out of, ensuing from or relating to any injury, death or damage to person or property resulting from or caused by participation in the below described event. Participant assumes all risk of injuries, including death, and loss or damage to Participant’s property, whether such risks are inherent to the activity or not. Nothing contained herein shall be construed or interpreted as a waiver of sovereign immunity of the State of Florida. I understand that volunteers on duty for the Department may be photographed or videoed and the materials may be used to promote the Department. No further releases are required.

I certify that as Participant, I have the sufficient level of physical conditioning required to complete the Event and that I meet the minimum requirements described above. I certify that there are no known medical reasons why I should not participate in the Event. In the event of an emergency, I give permission to the Department and its agents to provide emergency services to me and to obtain emergency medical care.

I understand that I am a Participant as identified above and I certify that I am over the age of 18 and have read and understand the above waiver and assumption of risk.

I hereby consent on behalf of myself and, if applicable, the below referenced minor child that any photographs or video in which I or the minor child appear as well as any audio recordings of my or minor child’s voice, may be used by the Florida Department of Environmental Protection (Department), Wekiva Wild and Scenic River System Management Committee, its assigns and successors, in whatever way it desires, including television and print ads, without compensation. I consent that the Department shall have the irrevocable, perpetual and unrestricted right and permission to take, use, re-use, publish, and republish pictures or video of me or the below referenced minor child, without restriction as to changes or alterations, in any and all media now or hereafter known, specifically including but not limited to print media and distribution over the internet for illustration, promotion, art, editorial, advertising, trade, or any other purpose whatsoever. I further consent that the state shall hold any and all resulting copyrights to any pictures, video, or audio recordings in which I or the below referenced minor child may appear in perpetuity and that the state may sell, reproduce, or make other lawful uses of any such pictures, video, or audio recordings.

Date Filled Out(Required)

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