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"M.T.O.A. TRAINING REGISTRATION FORM"

NAME OF COURSE
 ___________________________________________________________________

LOCATION OF TRAINING _____________________________________________________________

DATES OF TRAINING _____________________COST_______________________
Participant Name / Rank__________________________________________________________
Participant Agency / Unit ________________________________________________________
Agency Unit / Phone Number_____________________________________________________
LIABILITY WAIVER & INDEMNITY AGREEMENT

Intending that this agreement be legally binding upon me, my heirs, executors, administrators, and assigns, I hereby waive, release and forever discharge the Kansas City Metro Tactical Officers Association (MTOA), and all of their agents, representatives, heirs, executors, administrators, successors and assigns of and from all known and unknown, foreseen and unforeseen physical and mental injuries and consequences thereof, suffered by me during any and all training activities held during the training session attended by me.

In signing this release, I assert that (A) I am presently in good physical condition and mental health, (B) I have no reason to believe that I am not in good physical and mental health, (C) I am fully aware of, and do acknowledge and assume all risk of injury inherent in my participation in this training course, (D) I am not currently suffering from any affliction that would preclude me from participating fully in this training program, and (E) It is my responsibility to refuse to participate in any activity that I feel may cause injury to me or aggravate any existing injury or condition.

I HAVE READ, UNDERSTAND AND FULLY AGREE TO ABOVE AGREEMENT.

Date this ______ day of _______, 20___.


__________________________________________________________
Printed Full Name of Participant

___________________________________________________________
Signature of Participant


Printed Full Name of Witness__________________________________

Signature of Witness__________________________________________

This is to certify that the above listed officer is authorized by his/her agency to attend this training and is covered by Worker’s Compensation Insurance in the event that he/she is injured while attending this training session.

_________________________________                  ______________________________

PRINTED NAME OF SUPERVISOR                                               SIGNATURE OF SUPERVISOR

Date this_____ day of ________________, 200__.


EMERGENCY CONTACT NUMBER

Name _______________________________ Relationship__________________________

Phone Number(s)__________________________________________________________

EMERGENCY CONTACT

NAME______________________________________           RELATIONSHIP____________________

TELEPHONE NUMBER_(____)_________________

MTOA USE ONLY

Date Received________________________________            Date Notified_________________________

Amount Received_____________________________            Amount Returned_____________________

Please reproduce and use for ALL KCMTOA training.
MTOA ADMIN USE ONLY

Date received ________________________ Date notified _________________________

Amount received _____________________ Amount returned ______________________