Participant RANK, followed by FIRST and LAST NAME:
1. ________ ________________________ __________________________________
2.
________ ________________________ __________________________________
3. ________ ________________________ __________________________________
4.
________ ________________________ __________________________________
Home Telephone Number:
Participant Mailing
Address:
Street
City, State & Zip Code
By attending and participating in reenactments and living history
events, I recognize that there are risks attendant to this activity, including, but not limited to, open campfires, handling
and use of black powder, discharge of small arms and cannons, the risk of injury attendant to movement of large groups of
people, the presence and use of horses and/or other animals and risks associated with primitive camping. I hereby assume any
and all risks of danger occasioned by my presence and participation in any and all activities in any way related to the reenactment.
I further agree to release and hold harmless 77th Pennsylvania Volunteer Infantry Regiment, Inc., their agents, assigns, employees,
directors and officers from any and all claims for property damage or personal injury of any kind, no matter how incurred,
sustained during my presence at the reenactment or while on their properties. I hereby grant to the 77th Pennsylvania Volunteer
Infantry Regiment, Inc and its licensees, successors, and assigns the rights to make use of my appearance, actions, voice,
sounds and other attributes (collectively Appearance") and any part of them comprising or related to my attendance of
or participation in 77th Pennsylvania Volunteer Infantry Regiment, Inc reenactment(s) or living history events, related activities
(e.g., camp activities, the dances, etc.) and visits to sites or facilities in relation to those events (e.g., the battlefields,
the Visitor’s Centers, etc.). This grant shall be effective everywhere, perpetual, for an unlimited number of times,
and shall include the rights to photograph, film, depict, reproduce, distribute, record, transmit, store, display, make derivative
and edited works and otherwise exploit my Appearance and any part of it, in and through any media or means now known or hereafter
invented. I understand that 77th Pennsylvania Volunteer Infantry Regiment, Inc will rely on this grant and I fully intend
it to have legal effect.
I hereby agree to abide by the rules & regulations as stated for the 77th Pennsylvania
Volunteer Infantry Regiment, Inc.
ONLY FAMILY MEMBERS MAY SIGN ON SAME WAIVER
SIGNATURE:
DATE:
SIGNATURE:
DATE:
SIGNATURE:
DATE:
MINORS
(List names of Minors under 18 years of age):
Name:
Name:
Name:
The parent or guardian
has read and voluntarily signs the waiver and release of liability and indemnity agreement and does so voluntarily and with
the understanding that substantial rights are being given up. I/we further acknowledge that failure to witness or notarize
this agreement shall not affect its validity. I have read this release
_____________________________________________ ______________________________________________
Parent
or Guardian (Signature) Date, Father/Mother/Guardian Printed Name
