COSSIO INSURANCE ANGENCY

Paintball To Go = PTG Phone: (217) 589-5673

READ CAREFULLY

WAIVER AND RELEASE OF LIABILITY

In consideration of PTG furnishing services and/or equipment to enable me to participate in

paintball games, I agree as follows:

I fully understand and acknowledge that; (a) risks and dangers exist in my use of Paintball

equipment and my participation in Paintball activities; (b) my participation in such activities and/or

use of such equipment may result in my injury or illness including but not limited to bodily injury,

disease strains, fractures, partial and/or total paralysis, eye injury, blindness, heat stroke, heart attack,

death or other ailments that could cause serious disability; (c) these risks and dangers may be

caused by the negligence of the owners, employees, officers or agents of PTG; the negligence of the

participants, the negligence of others, accidents, breaches of contract, the forces of nature or other

causes. These risks and dangers may arise from foreseeable or unforeseeable causes; and (d) by my

participation in these activities and/or use of equipment, I hereby assume all risks and dangers and

all responsibility for any losses and/or damages, whether caused in whole or in part by the

negligence or other conduct of the owners, agents, officers, employees of PTG, or by any other

person.

I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to

release, waive, discharge, hold harmless, defend and indemnify PTG and it’s owners, agents, officers

and employees from any and all claims, actions or losses for bodily injury, property damage, wrongful

death, loss of services or otherwise which may arise out of my use of Paintball equipment or my

participation in Paintball activities. I specifically understand that I am releasing, discharging and

waiving any claims or actions that I may have presently or in the future for the negligent acts or other

conduct by the owners, agents, officers or employees of PTG. This waiver is good through 3/1/2013.

MEDICAL PERMISSION AUTHORIZATION

If the participant is of minority age, the undersigned parent or guardian hereby gives

permission for PTG to authorize emergency medical treatment as may be deemed necessary for the

child named below while participating in paintball games.

I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE IT IS MY INTENTION TO

EXEMPT AND RELIEVE PTG FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL

DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.

Print Name ___________________________________ Age __________ Date of Birth ______

Phone ________________________

Signature ___________________________________ Address ____________________________

City, State Zip ________________________

Signature of Parent/Guardian (if less than 18 years old)

_______________________________________________

E-mail__________________________________________

Date___________________________________