IMPORTANT: THIS IS A LEGAL DOCUMENT
Please read and understand this document before signing. If you have any questions please ask us or consult an attorney.
Morale, Welfare and Recreation (MWR), NSA Naples, Italy (U.S. Navy), as well as, NSA Naples, Department Gaeta, Italy (U.S. Navy), and their respective staffs have taken reasonable measures to assure that our patrons have a rewarding experience while participating in a MWR activity or event. We wish to inform our patrons that our events are not risk free.  We do not want to heighten or reduce your enthusiasm for the experience, but we do want you to know in advance what to expect, and to be informed of some of the possible risks. We ask that you read, sign, and return this document to our office.
TRANSPORTATION ACKNOWLEDGMENT OF RISKS
As part of the _______ trip, MWR Department provides transportation by motor vehicle, van, or bus to and from the starting and ending point.  I understand and agree that I  shall not hold MWR Department liable for any injury I received due to the transportation MWR Department provides.  I agree that terms of this release shall cover any injury I receive due to an accident on the part of MWR Department whether by their negligence or the negligence of others.  

I understand the need for all passengers to exercise particular caution when on the vehicle, and especially while moving around the interior of the vehicle while it is in transit.  I further understand that I may be subjected to a variety of hazards and risks, foreseen or unforeseen, for example, possibility of bodily injury (broken bones and soft tissue damage) including dental damages , injuries incurred while getting on or off (in or out of) the mode of transportation being used for the event, being knocked down, paralyize or death("Damages").  I shall voluntarily assume the risks of any and all Damages I may incur on MWR Department.

I understand that while on the MWR Department trip there will be times when access to rescue or medical facilities or expertise may be several hours or even days away from the location where these Damages may occur. I understand that being exposed to such Damages, risks, and hazards are inherent in participating in MWR Department trip.  I understand that I shall exercise extra care for my own person. Notwithstanding these factors, I choose to take this journey, agree to pay the required costs, and voluntarily assume the risk of Damages occurring while I am on ______________ trip. 

MWR Department may deliver passengers to various third parties who will conduct, supervise, guide, or instruct passengers in various sporting or recreational activities, or conduct entire tours. MWR Department assumes no duty to certify, monitor or verify the qualifications of any third parties involved in these activities. Passengers' may direct concerns regarding the qualifications of any third parties conducting or supervising these activities to the third parties.  Passenger agrees to release, indemnify and hold harmless Navy MWR Department and its staff, and the U.S. Navy, and its members, agents and employees for liability for Damages arising out of the negligence of such third parties. 

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Patron’s initials

WAIVER AND RELEASE
I certify that my family, including minor children, and myself are fully capable of participating in ___________ trip. I have read the above statement on some of the possible risks in the MWR Department trip/program or activity. I assume full responsibility for myself, my family, including minor children, for bodily injury, death and loss of personal property and any expenses as a result of my negligence, negligence of my family, negligence of another participant on the MWR Department, trip/program or activity, or the negligence of MWR Department and its staff. I also understand that MWR Department may refuse any person it judges to be incapable of meeting the rigors and requirements of participating in MWR Department, trip/program or activity.  My family and I are in good physical condition and able to undertake this activity.

I authorize and release to MWR Department and its staff the use of my image in any photograph or video recording for any purpose of MWR Department.

I have adequate health, disability and life insurance for my family and myself.
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Patron’s initials

INDEMNIFICATION

I indemnify and hold harmless MWR Department and its staff, and the U.S. Navy, and its members, agents and employees from all claims, damages, losses, injuries and expenses arising out of or resulting from participation on this trip. I further agree to release, acquit and covenant not to sue MWR Department and its staff, and the U.S. Navy, and its members, agents and employees for all actions, causes of action claims or damages, damages in law or remedies in equity of whatever kind, including the negligence of MWR Department its staff or my family, myself, or my heirs, against MWR Department arising out of participation in the MWR Department, trip/program or activity I shall not  sue MWR Department and its staff, and the U.S. Navy, and its members, agents and employees, and if I do, I shall not collect any money.

I agree to the site of any lawsuit and the law governing any such lawsuit shall be governed the Federal Tort Claims Act, Military Claims Act, Foreign Claims Act, Suits in Admiralty Act, Public Vessels Act or Admiralty Extension Act, whichever is applicable. The terms of this agreement shall continue and be in effect after the MWR trip/program or activity has ended. I hereby give permission for transportation to any medical facility or hospital and I authorize any guide, or medical personnel to render necessary emergency medical care for my family or me.  I authorize the release of any medical information in the possession of MWR Department to any medical facility or hospital, ambulance, first aid provider, first aid service, doctor, nurse or other such person rendering care on my behalf.  I waive any action or claim against MWR Department and its staff or any health care provider, hospital, doctor, nurse or first aid provider for the release of this medical information.

If MWR Department and its staff, and the U.S. Navy, and its members, agents and employees are forced to defend any action, lawsuit or litigation by myself, my executors, or my heirs, on my family's or my behalf; accordingly, I shall pay court costs and attorney fees if they successfully defend such action, lawsuit or litigation. 

Should a court of competent jurisdiction declare any paragraph or part of this agreement enforceable, the remaining parts or paragraphs shall remain in full force and effect.

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Patron’s initials

I, _________________________________________________, of my own free will, for my family, my minor children, my heirs and executors and myself, have read, understand and acknowledge the risks and liability for myself, and my family this _______ day of ___________________________ 

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Patron’s initials

I have read and understood this agreement.
			
FIRST PARTICIPANT SIGNATURE		SECOND PARTICIPANT SIGNATURE
			
PRINTED NAME		PRINTED NAME
			
ADDRESS		THIRD PARTICIPANT SIGNATURE
__________________________________________            _________________________________________		PRINTED NAME
                                                                                                
PHONE: [_____]________________			
IN CASE OF EMERGENCY PLEASE CONTACT: _______________________________________________
PHONE: __________________________________________________________________________________
I CARRY MEDICAL INSURANCE. YES _________ NO _________ GROUP NUMBER: _______________
NAME OF PROVIDER: ____________________________________________________________________