PARTICIPANT LIABILITY RELEASE/CONSENT AND INFORMATION RELEASE I, _____________________________________, (the “Participant”) intending to be legally bound, understand and agree that I am voluntarily participating in Make-A-Wish Foundation ("MAW") Ride For Wishes (the "Ride") and all of its activities including, but not limited to, training for and participating in the following event:_Ride For Wishes 2009___ _ (collectively, the “Event”) at my own request and at my own risk. I acknowledge that I am aware of the risks inherent in training for and participating in the Event and certify that I am physically fit, have not been otherwise informed by any physician and know of no restrictions imposed on me by any physician that would in any way prevent me from actively participating in the Event. In consideration of MAW’s sponsorship of this Event and my being permitted to participate in the Event, I, on behalf of myself, my successors in interest, heirs, assigns, and representatives, hereby fully release and hold harmless MAW and its chapters, their Officers, Trustees, agents, employees, volunteers, any medical providers working for or on behalf of the Ride, and representatives, successors and assigns (be they individuals or organizations), together with their insurers and sponsors (collectively, the “Foundation”), of and from any and all liability, claims, damages, actions and causes of action whatsoever on account of any loss, damage or injury to person (including death) or any other loss or inconvenience whatsoever, suffered by me at any time hereafter arising out of my voluntary participation in this Event, whether resulting from the Foundation’s negligence or otherwise (collectively, “Liabilities”). I also give permission to the Foundation to freely use of my name, picture and voice in any broadcast, telecast, print account, or any other account in any medium of this Event (the “Personal Release”). I understand that this Personal Release is perpetual in time and that it encompasses, without limitation, any copyright or right of publicity or privacy that I may have in my name, picture and voice. Consent and Information Release ("Consent"): I hereby grant permission to the Foundation to render preventative or first-aid assistance or seek treatment or medical care that it seems reasonably necessary, including hospitalization, for my health and well being. I also give permission to the Foundation to use and disclose my personal health information ("PHI") in the ways described in this form. I allow the Foundation to use my PHI as necessary for purposes related to my treatment. I also allow the Foundation to give out my PHI to doctors, hospitals, ambulance companies, coaches, family members, and others involved in my care and treatment. My PHI may also be used and given out as necessary to run the Event or as necessary for the proper management and administration of the Foundation. This Release and Consent will be governed by and subject to the laws (except the choice of law principles) and exclusive jurisdiction of the courts of the State of Alabama. Date: __________ _____________________________________________ Signature of Participant *Must be signed also by parent or legal guardian if the Participant is under age 18 on the date this Release and Consent is signed. I, the undersigned, hereby certify that I am the parent or legal guardian of the Participant, and as such and on behalf of myself and the Participant, I agree to the terms of this Release, including the Consent, on behalf of the Participant and I hereby, in accordance with the terms of such Release, release and hold harmless the Foundation (as defined above) from all Liabilities (as defined above). Date: _______________ ____________________________________________ Signature of Parent/Guardian