KENTUCKY DEPARTMENT OF PARKS

WAIVER OF LIABILITY CLAIMS

Park Name: __________________________________________________

Event: __________________________________________________

Date of Event: _______________ _____, 2012

 I, _______________________________, the undersigned, plan to participate in

______________________________ (name of activity) at ________________________ (name of

state park) on ________________ _____, 2012 (date of activity).

In case of an accident or injury during this activity, I hereby covenant, promise and agree for myself, my personal representatives, heirs, and next of kin that neither the Tourism, Arts and Heritage Cabinet, Kentucky Department of Parks, nor __________________________ (name of state park), any of its agents, officers or employees shall be held responsible or liable for any negligence, implied or otherwise, for personal injury or damages suffered or sustained by me in connection with, arising out of, or resulting from any and all activities associated with the abovementioned event.

_______________________________________________________________________________
Participant Name (Please Print)

_______________________________________________________________________________
Participant Signature                                    Date

_______________________________________________________________________________
Witness Name (Please Print)

_______________________________________________________________________________
Witness Signature                                        Date