Please note: if a person is under 18 years of age, parent or legal guardian must sign this form.

I hereby give my permission to Mary Free Bed Rehabilitation Hospital of Grand Rapids, Michigan, to use my (or my child’s) name and/or likeness, city and state, in
the form of photographs, videotape, interviews, slides, movies, or recordings, and the use of statements made by me or attributed to me (or my child) for publicity
purposes or similar promotions relating to Mary Free Bed Rehabilitation Hospital, including use on the Mary Free Bed Web site. Furthermore, I grant Mary Free
Bed Rehabilitation Hospital any and all rights to said use without further compensation. It is my understanding that my signature below releases Mary Free Bed
Rehabilitation Hospital from any financial or legal responsibility for the use of the media relations/advertorial/promotional materials named above.

In consideration of the risk of injury or illness that exists while participating in a sport or recreational event held by Mary Free Bed Wheelchair and Adaptive Sports.

I hereby, for myself and/or my minor child, consent to voluntarily participating in the above activity.

I am aware of the risks associated with participating in this activity, including that associated with the exposure of communicable diseases, including, but not limited to, Covid-19.

I am aware that Mary Free Bed Rehabilitation Hospital will follow CDC guidelines as it relates to prevention of illness, but that I, and/or my minor child, will participate in the activity entirely at my, or my minor child’s, own risk.

I hereby certify that the participant does not have any symptoms of/ tested positive for Covid-19, or has been exposed to anyone that has had symptoms of/has tested positive for Covid-19 in the last 14 days. These symptoms include:

• Fever
• New or worsening cough with respiratory illness
• Sore throat with respiratory illness
• Difficulty breathing or shortness of breath
• Chills or shaking with chills
• Loss of taste/smell

I understand that it is my duty to notify Mary Free Bed Rehabilitation Hospital if any symptoms or exposure develop prior to the event. In the event that symptoms or exposure does arise, I, and/or my minor child, agree not to attend the activity.

I understand that risk of infection may arise from my own or others’ negligence, including contact with other participants. Nonetheless, I assume all related risks, both known and unknown to me and/or my minor child’s participation in this activity.

I agree to indemnify, defend and hold harmless Mary Free Bed Rehabilitation hospital, it’s employees, agents, and volunteers, against any claims, suits or actions of any kind whatsoever for any and all injuries, illness, liability, damages, compensation or otherwise brought by me or anyone on my behalf.

I agree that Mary Free Bed Rehabilitation Hospital, its employees, agents, and volunteers, are not responsible for errors, omissions, acts or failures to act of any party or entity conducting the specific event or activity on behalf of Mary Free bed.

In the event that I should require medical care or treatment, I authorize Mary Free Bed Hospital to provide or access emergency medical care as they deem necessary, including but not limited to first aid, CPR, use of AED’s, emergency medical transport. I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment.

I authorize the release of medical information with medical personnel upon initiation or transfer of medical care.

I hereby acknowledge that I have carefully read this “Waiver and Release” and fully understand that by signing this, I agree to release and hold harmless Mary Free Bed Rehabilitation Hospital, employees, agents, and volunteers from any and all claims related to my participation.

Please note: if a person is under 18 years of age, parent or legal guardian must sign this form.

I, the undersigned (participant), being of lawful age or have, of my own accord, chosen to participate in Mary Free Bed programming. I am being permitted to participate at my own risk and assume full responsibility for any injuries or damages that may occur to me or my equipment during or in transit to and from the program(s).
In consideration of being allowed to participate in MFB programs, I, the undersigned, for myself, my heirs, my successors and assignees, agree to indemnify and
forever hold harmless Mary Free Bed Rehabilitation Center, Mary Free Bed directors, officers, members, agents, and employees, and their respective agents, successors, legal representatives, heirs and legatees and each of them from and against any and all claims suits, damages, losses, expenses (including attorney fees), and liabilities which they or any of them may occur to be subjected to in any way be reason of, arising out of, or related to my participation, including my equipment or provided equipment and travel to and from programs, excluding any claims arising out of the negligence of the MFB leaders or otherwise of the program.
I am in good health and may participate in wheelchair/adaptive sports. My activity should not be limited or participation hindered because of any physical ailment. I realize that any sport may cause an individual serious injury and the participation in any sport is an acceptance of some risk of injury. If any emergency arises involving my physical well-being. I give MFB full permission to protect and assist me as deemed necessary. I will agree to pay any medical expenses or any other expenses related to my participation.

I certify my signature (below) signifies consent with this release.