KOUNTRY KAYAKS LLC                                                                                                                   LOGO

604 COUNTY ROAD 19

KITTS HILL, OHIO 45645

(740) 533-1901

KOUNTRYKAYAKSLLC.COM

FACEBOOK “KOUNTRY KAYAKS”

Name_____________________________________ Birth Date (mm/dd/yy)________________________

Mailing Address________________________________________________________________________

City____________________________________ State__________________ Zip Code________________

Email Address_________________________________________________________________________

Home Phone______________________________ Cell_______________________________

Emergency Contact_______________________________________ Phone________________________

Please read carefully and be certain that you understand the implications of signing. Please fill in all blanks and initial each paragraph before signing at bottom. Kountry Kayaks LLC is registered with the State of Ohio and will throughout this document be referred to a “KKLLC”.

I, (Please print full name),__________________________________________________________, do hereby affirm and acknowledge that I am aware of the inherent hazards and risks associated with watercraft, adventure outings, and handling and transportation of equipment related to the activities in which I am about to engage. Inherent hazards and risks include but are not limited to:

1.        Risk of injury from the activity and equipment utilized is significant, including the potential for permanent disability and death.

2.        Falling; causing broken bones, severe injury to head, back, neck may result in severe impairment or even death.

3.        An “act of nature”; including but not limited to land or rock slide, flash flood, inclement weather, lightning, wind, extreme temperatures.

4.        Risks associated with hiking, climbing, crossing rocky, muddy, slippery, rough, steep terrain.

5.        Risks associated with paddling, ferrying, river crossings, portaging, swift currents, eddies, cold water, and wakes from other watercraft.

6.        Possible equipment failure and/or malfunction of equipment which may have been rented, borrowed, or personally owned.

7.        My own negligence and/or the negligence of others; including employees, agents, independent contractors or representatives of KKLLC, including but not limited to operator fatigue.

8.        Cold weather and/or heat related injuries and illness including but not limited to immersion accidents, hypothermia, frostbite, heat exhaustion, heat stroke, sunburn, dehydration.

9.        Attack by or encounter with insects, reptiles, spiders, snakes, and/or other wildlife or domestic animals.

10.     Accidents or illness occurring in remote places where there are no available medical facilities or access to 911 or other emergency services.

11.     Swimming or diving accidents which could result in injury, paralysis, drowning, and death.

12.     Fatigue, chill, and/or dizziness which may diminish my/our reaction time, my sense of balance, physical coordination, and ability to follow instructions and increase the risk of an accident.

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I understand that the use of kayaks, paddleboards, and related equipment in any body of water can be hazardous. I am responsible for my competence as a participant in this activity. Watercraft may overturn or sink. Underwater obstructions, hazardous currents, undercut banks, overhanging vegetation, and other hazardous conditions both natural and manmade may exist in a rivers, creeks, ponds, or lakes. Diving into the water from a kayak or canoe, adjacent banks, over-hanging trees, rocks, or bridges can be extremely hazardous in that underwater obstructions may be struck by the diver resulting in serious injury including paralysis and/or death. The undersigned hereby acknowledges that KKLLC, its agents, employees, representatives, and volunteers have no control over the above mentioned hazards, weather, and water conditions which may result in my injury or death.

I UNDERSTAND THAT THE DESCRIPTION OF THESE RISKS IS NOT COMPLETE AND THAT UNKNOWN OR UNANTICIPATED RISKS MAY RESULT IN MY INJURY AND/OR DEATH.

It is the intention of (print full name)______________________________________ by this instrument  do EXEMPT, RELEASE, AND HOLD HARMLESS KKLLC, my instructor or guide (if any), the members of KKLLC, its  officers, directors, employees, representatives, agents, volunteers, and all related entities and release parties or as defined above, from all liability or responsibility whatsoever for personal injury, property damage or wrongful death however caused, or rising out of, directly or indirectly, including, but  not limited to the negligence or recklessness of the released parties whether passive or active. I have full informed myself of the contents of this liability release and express assumption of risk by reading it before signing it on behalf of myself, my heirs, my estate, and assigns. By executing this document I agree to hold KKLLC harmless and indemnify them in conjunction with any injury, disability, death, or loss, or damage to person or property that may occur as a result or engaging in outdoor activities. I am responsible for myself and my decisions, and am willing to accept risks of this activity.

A personal flotation device (PFD will be provided by KKLLC. I understand that failing to use a PDF can greatly increase my personal risk and that most states including, but not limited to The Ohio Department of Natural Resources, require their use. I understand that am obligated to follow all local, state, and federal laws and will be personally responsible for any penalties for their infractions.

My presence and/or activity(s) on Federal, State, or private property may require special fees or license(s). (ie. fishing, hunting, trail use, etc. permits). I acknowledge that I am responsible for obtaining these permits and that KKLLC has no responsibility for my compliance. I AGREE NOT TO BE UNDER THE INFLUENCE OF ALCOHOL OR DRUGS THAT CAN AFFECT MY JUDGEMENT, PERCEPTION, OR PHYSICAL MOVEMENT WHILE PATICIPATING IN ANY AND ALL ACTIVITIES.

All rental equipment will be returned at the agreed upon time to avoid late charges. I understand that KKLLC does not provide personnel or equipment for “rescue” operations. If a client requires “rescue” they will be responsible for any expenses incurred by rescue party and/or agencies. 

I accept the equipment rented “as is” and accept full responsibility for its care and wellbeing while it is in my possession. Replacement or repairs will be accessed at FULL RETAIL VALUE. Damage due to improper use, abuse, or improper handling of equipment is my responsibility and I agree to pay any incurred cost due to repairing or replacing equipment to KKLLC

I hereby grant KKLLC, its representatives, and employees the right to take/use photographs and/or video of me in connection with my participation in activities. I authorize KKLCC to copyright, use, distribute, and publish same in print and/or social media. I hereby agree that KKLCC may use such photographs and videos for any lawful purpose, including but not limited to publicity, illustration, advertising, television, and web content.

I, the undersigned, certify that I have no medical or physical conditions which could interfere with my safety or successful participation in this activity. I further acknowledge that I have responsibilities as a participant, and I assume and accept full responsibility for myself. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.

This release shall be binding to the fullest extent of the law. If any provision is found to be unenforceable, I agree that the remaining terms shall be fully enforceable.

(Initial)____________ I certify that I am of lawful age and legally competent to sign this liability release.

I HAVE HAD SUFFICIENT OPPORTUNITY TO READ TGIS ENTIRE RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, AND I FULLY UNDERSTAND ITS TERMS, AND UNDERSTAND THAT I HAVE GIVEN UP LEGAL RIGHTS BY SIGNING IT. I SIGN IT VOLUNTARILY AND WITHOUT INDUCEMENT AND AGREE TO BE BOUND BY ITS TERMS.

________________________________________________________ Date__________________

(Signature of Participant/Renter)

________________________________________________________ Date__________________

(Printed name of witness)

________________________________________________________ Date__________________

(Legal signature of witness)

I, ________________________________________________ (full name of parent/ legal guardian), hereby agree that I will explain to my child that the risk of injury while participating in the activities/programs can be reduced by following the rules and through the use of common sense and good judgment. This is to certify that I, as Parent, Guardian, Temporary Guardian with legal responsibility for this participant, do consent and agree not only to his/her release of KKLCC, but also to release and indemnify KKLCC from any and all liabilities incident to his/her involvement in these activities for myself, my heirs, assigns, and next of kin.

________________________________________________________ Date_________________

(Signature of Parent/Legal Guardian

________________________________________________________ Date_________________

(Full name of Minor Participant)