Release and Waiver of Liability and Indemnity Agreement
I have been advised of the nature and extent of my injuries sustained on ____________________________, 20__, while participating in _______________________________________________________________ at ___________________________, located in ___________________________________. This injury was treated by ____________________________in ______________________________. The team physicians have discussed the following treatment options along with the possible outcomes, including any adverse effects if present, of such treatment that I choose to receive.
The physicians have discussed any possible risks of my continued participation in ___________________ following the injury described above including:
I understand the information that has been presented to me regarding possible treatments and continued participation. All of my questions have been answered to my satisfaction.
Signature______________________________________________________________________________
Witness _______________________________________________________________________________
Date _____________________________________