Waiver and Release of Liability Agreement

In connection with my participation in the Heart Run/Walk, I agree to the following:

I will be participating in the Heart Run/Walk as either a runner or volunteer.  My participation may include (but are not limited to) the following activities, regardless of whether the activities occur before, during or after the Heart Run/Walk: as a runner, performing warm-up and stretch exercises, walking and running; and as a volunteer, carrying and lifting course supplies and traveling to and from designated volunteer assignments (“Activities”).

I represent that I am in good health and that I do not suffer from any physical condition that would prevent me from safely participating in the Activities.

I understand and fully assume all risks and responsibilities for losses, costs, and damages I incur as a result of my participation in the Activities.

I HEREBY RELEASE, WAIVE, COVENANT NOT TO SUE, AND FOREVER DISCHARGE (1) BELLIN HEALTH SYSTEMS, INC.; (2) ITS AFFILIATES; AND (3) AND EACH OF THEIR OFFICERS, DIRECTORS, MANAGERS, EMPLOYEES, AGENTS, VOLUNTEERS, AFFILIATES, SUCCESSORS, AND ASSIGNS (HEREINAFTER COLLECTIVELY “RELEASED PARTIES”) FOR ANY AND ALL DAMAGES, COSTS, LOSSES, EXPENSES, DEMANDS, CLAIMS, OR CAUSES OF ACTION FOR ANY BODILY INJURY,  PROPERTY DAMAGE, EMOTIONAL DISTRESS, OR LOSS OF SOCIETY THAT IS CAUSED, WHETHER DIRECTLY, INDIRECTLY, OR CONSEQUENTIALLY, INCLUDING AS A RESULT OF NEGLIGENCE, BY ANY OF THE RELEASED PARTIES AND THAT RELATES TO OR ARISES OUT OF MY PARTICIPATION IN THE ACTIVITES.  

I understand that bodily injury may include, but not be limited to, minor injuries such as bruises and/or sprains; major injuries such as fractures, internal injuries, joint or back injuries, heart attacks, and/or concussions; or catastrophic injuries such as paralysis or death.

I understand such negligence could include the Released Parties’ failure to use reasonable care in, without limitation, selecting, maintaining and securing the course for the Heart Run/Walk; selecting, training, or supervising employees or volunteers; selecting, approving, or maintaining safety procedures or equipment; providing instructions on the use or selection of equipment; providing other instructions; or providing first aid or emergency medical care.

I acknowledge that the Released Parties do not carry or maintain health, medical, or disability insurance coverage for me to participate in the Activities, and that I am expected and encouraged to have medical or health insurance coverage in effect at the time of my participation. 

I agree that if any portion of this Liability Release and Waiver Agreement is held invalid, the balance shall continue in full legal effect.

I acknowledge that I have had the opportunity to review, discuss, ask questions about and negotiate the terms and conditions of this Liability Release and Waiver Agreement and understand that, if I wish to further discuss any of its terms, I may contact the Bellin Health Legal Department at (920) 433-3782.

I HAVE READ THIS LIABILITY RELEASE AND WAIVER AGREEMENT, I UNDERSTAND AND VOLUNTARILY ACCEPT ITS TERMS, AND I UNDERSTAND THAT I WILL BE GIVING UP SUBSTANTIAL RIGHTS BY SIGNING THIS LIABILITY RELEASE AND WAIVER AGREEMENT.  I AM EIGHTEEN YEARS OF AGE OR OLDER, I HAVE FULL CAPACITY TO ENTER INTO THIS AGREEMENT ON BEHALF OF MYSELF AND DO SO VOLUNTARILY.

Right to Treat: As a participant in the Marinette Heart Run, I understand I may become ill or injured and medical treatment may be necessary. I give consent to Bellin Health medical staff and/or volunteers to evaluate, treat injuries/illnesses, and activate emergency care as indicated.

Photograph/Videotape Authorization: I hereby give Bellin Memorial Hospital, Inc., and its affiliates, permission to photograph or videotape me during the run and its related activities, and to use those photographs or videos for any purpose, including but not limited to commercial purposes, Emplify Health advertisements and promotional materials.

Acknowledgement Statement

I acknowledge and agree that I am about to provide certain individually identifiable information to RunSignup.  I intend to provide this information to RunSignup for the purpose of registering for the Emplify Health Marinette 5K Heart Run (“Event”) and other related purposes.  

I understand that this Event is being sponsored by Bellin Memorial Hospital, Inc. (“Bellin”).    Therefore, I also understand that Bellin will be receiving individually identifiable information about me directly from RunSignup.

By entering my name below, I hereby affirm the following:

I do not intend to provide individually identifiable information to RunSignup and Bellin in connection with any health care services or payment for health care that I have received, am receiving, or will receive from Bellin; and I am not seeking any health care services or benefits from Bellin as part of my registration in the Event; and
If I am providing individually identifiable information for a person other than myself (such as my minor child), then it is my desire that the statements above apply to this person’s information in the same manner it applies to my own information.