STATE OF HAWAII
DEPARTMENT OF LAND AND NATURAL RESOURCESRELEASE OF LIABILITY

Name:

Phone:

Address:
I have requested the Department of Land and Natural Resources to allow me or mychild to engage in the following activity or activities on State of Hawaii property
known as the(hereinafter “Park”):(Description of activity)
for a period of time starting onand endingon. I agree and acknowledge that my or my child’s SAFETY is at
moderate to high risk and that I accept RESPONSIBILITY. I fully understand, andby my signature acknowledge that:I recognize and acknowledge that there are certain inherent risks and dangers involved
with the above-described activity or activities at the Park involve certain inherent risks
including but not limited to risk of possible injury or death and understand that thefollowing conditions, hazards, or dangers may exist:• gusty winds• dense, tangled vegetation• sharp and/or slippery rocks• thorny plants• stinging or biting insects and spiders• work on or near steam and ocean water• portable or no bathroom facilities• wet or slippery roads• no potable drinking water• herbicides• steep drop-offs• paint, fuel, and oil fumes• rugged terrain• work in hunting area

• sharp tools• wild animals• lack of nearby medical facilities• steep and slippery trail and rivercrossings• harsh weather conditions (ranging fromhot and humid to wet and cold)• flash floods• lack of reliable communication service(including no telephone service)• diseases caused by water, air, or animal
vectors

To the extent that my activities may involve the use of motorized tools, hand tools,
and/or handling of herbicides, I acknowledge that there are certain inherent risks anddangers involved in such activities, which include (but are not limited to) risk ofpossible serious bodily injury, death, or poisoning.

Release of Liability for StateParks

Page 2

Knowing that the above-described activity or activities at the Park may present certain
risks and dangers to me or my child, including A RISK OF SERIOUS BODILY HARM
OR DEATH, I nevertheless permit myself or my child to engage in the above-describedactivity or activities at the Park. I voluntarily ASSUME THE RISK OF INJURY OR LOSS
created by the above-described conditions, hazards, and dangers at the Park.
With full knowledge of said conditions, hazards, and dangers, I RELEASE AND
AGREE TO INDEMNIFY AND HOLD HARMLESS the State of Hawaii, and any and allof its officers, employees, and agents, for death or injury to me or my child or damage
to or destruction of any of my or my child’s property resulting from the conditions,hazards, and dangers listed above.
I understand and acknowledge that the provisions of Chapter 90, Hawaii Revised
Statutes, do not apply to my or my child’s activities at the Park.
In consideration for allowing me or my child to engage in the above-described activity
or activities at the Park which I have requested, I, for my heirs, beneficiaries, executors,and administrators, REMISE, RELEASE, AND FOREVER DISCHARGE the State ofHawaii, and any and all of its officers, employees, and agents, acting in their official
capacities, from any and all claim(s), demand(s), or cause(s) of action on account of myor my child’s death or personal injury or on account of any injury to my or my child’s
property which may occur from my or my child’s negligence, hazards listed herein, oran unforeseeable event, during my or my child’s activity or activities at the Park
described above.
I have read the above waiver and hereby release the State of Hawaii, its officers,employees, agents, and assigns from any and all liability that may result from myabove-described activity or activities at the Park.
Signature:

Date:

Printed Name:
Signature of Parent or Legal Guardian:Printed Name:
Minor’s Name(s):Date: