Waiver of Liability
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10/12/2017
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Waiver of Liability Form
Guest Information
First Name:
Visiting As:
Last Name:
Salutation:
(Pastor, Priest, Doctor, etc.)
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
 
WAIVER OF LIABILITY AND FULL RELEASE OF CLAIMS
Upon consideration for entering upon the premises of POTTER'S RANCH, the below signed individual, being an adult of legal age, signing on behalf of himself, or herself, or as the legal custodian or parent of a minor who will be entering upon said premises for the purposes of (Please check all that apply)
SELECT ALL
ZIP LINE
BOATING ACTIVITIES
CHILDREN'S INFLATABLES
HAYRIDE
VOLUNTEER WORK
VENDOR SPONSORED ACTIVITIES
HORSE PROGRAMS
ATV RIDING
ROPES CHALLENGE COURSE
PAINTBALL

As and for consideration for entering upon such premises, I, on behalf of myself, or on behalf of the minor described herein, hereby agree to waive all liability, claims, causes of action, demands, whatsoever, against POTTER'S RANCH OR ANYONE AFFILIATED PERSONALLY WITH THE FOUNDATION, including directors, employees and agents, arising out of any incidents which may occur on said premises resulting in injury or damage to me or any of the parties described herein for whom I am signing this Waiver of Liability. It is understood that this Waiver of Liability is being made by myself on behalf of any heirs, executors, administrators, devises, legatees, and agents of mine or those persons for whom I am signing, and is intended as a complete and total Waiver of Liability for any claims, demands, causes of actions, whatsoever, arising out of my entering upon the above-described premises, and that further, without this Waiver of Liability, Potter's Ranch would not permit me upon the premises, and that I voluntarily assume any risks inherent in the above activities.

I recognize taht swimming in the creek on or adjacent to Potter's Ranch property is NOT permitted, authorized, or suffered by Potter's Ranch, and, in fact, is STRICTLE prohibited; liability, damages and causes of action, for any violations of this provision by the guest, or guest supervisor, or any minor under the adult's supervision is hereby RELEASED and WAIVED. The group, or, where applicable because the within waiver is being signed by and on behalf of an individual only, the adult signed below, agrees to assume responsibility for enforcing this "no swimming" policy, and further agrees to indemnify and hold Potter's Ranch harmless for any violation of that policy, in his/her capacity as an individual or as a representative of the legal entity which he/she represents.
Photo Release Statement and Permission to Use Photographs: By accepting the following: I grant permission for Potter's Ranch to use photos taken in connection with the above-identified activities. I authorize Potter's Ranch, its assignees and transferees to copyright, use and publish the same in print and/or electronically.

During my stay on the premises, I agree to abide by all rules and regulations of the Ranch as posted at the Registration Desk of this event. WARNING - Under Kentucky law, a farm animal activity sponsor, farm animal professional, or other person does not have the duty to eliminate all risks of injury of participation in farm animal activities. There are inherent risks of injury that you voluntarily accept if you participate in farm animal activities. KRS 247.4027

Authorization
Date MM/DD/YYYY: (date of first days event)
AUTHORIZED BY: (must match guest name as above)
NOTE: If signing on behalf of a minor, use the below lines
Minor's Name Date of Birth NAME OF PARENT/LEGAL GUARDIAN