Please Check One:
Camp________Site#________
Hike______________
Lake______________
Mtn Bike____________
All of the Above_______
Recreational Member Waiver Statement
Valley Branch Retreat INC.
2620 Valley Branch Rd.
Nashville, IN. 47448
(812)988-7750
I recognize that off-road bicycle, hiking, biking, swimming,
fishing, use of a canoe, or paddle boat, and paintball are all hazardous
activities and carry with the activity a potential for death, serious injury,
and property loss. I hereby assume the risks of participating in this
activity. In the event of an injury to myself or my child, and I render
such treatment as would be normal, and agree to pay the charges for such
treatment. I now release the Valley Branch Retreat Inc. and Rhoden LLC,
its employees, agents, and assigns for any personal injuries or damages to
property caused by or having any relation to this activity. I now release
VALLEY BRANCH RETREAT and RHODEN LLC., its employees, agents, and assigns for
having any relation to this activity. I understand that this release
applies to any present or future injuries and that it binds my heirs, executors,
and administrators. I have read this release and understand all of its
terms. I sign it voluntarily and with full knowledge of its significance.
____________________________
________________
Signature
Date
____________________________
E-Mail Address
_____________________________
Parent/ Guardian Signature
Print Names of Person and your children using facility
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Address__________________________________________________________________
Phone____________________________________________________________________
Valley Branch Retreat
Witness____________________
Date________________
Time IN______________
Time OUT________________