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<?php
$first_name = isset($first_name)?$first_name:"";
$last_name = isset($last_name)?$last_name:"";
$rid = isset($rid)?$rid:"";
$ip_add = isset($ip_add)?$ip_add:"";
$date_time = isset($date_time)?$date_time:"";
?>
<!-- Start Service Section -->
<section class="pad-t100 pad-b70">
<div class="container">
<div class="row">
<div class="col-md-6">
<div class="section-title left" style="margin-bottom: 50px;">
<h3>Release of Liability</h3>
</div>
</div>
<div class="col-md-6">
<blockquote class="primary mbl-mar-top">
<p>Due to our insurance policy, we are required to have each participant electronically sign the Waiver and Release of Liability form.</p>
</blockquote>
</div>
</div>
<div class="row" style="margin-top: 50px;">
<div class="col-md-12">
<div class="feature-3">
<a href="#" class="text-center"><h4>Vermont Corporate Cup Challenge & State Agency Race</h4></a>
<div style="margin-bottom: 40px">
<h5>Waiver & Release of Liability</h5>
<p style="margin-top: 20px;">I desire to participate in the Vermont Corporate Cup Challenge and State Agency Race ("Race").</p>
</div>
<div style="margin-bottom: 40px">
<h5>I. Identification of Risk</h5>
<p style="margin-top: 20px;">I, the above named competitor, know that the running or walking in the Race involves risks of serious injury, including but not limited to falls, contact with other participants, the impact of weather including high heat and/or humidity, permanent disability and death. I understand that injuries, loss or damage might result not only from my actions, but the actions or negligence of others.</p>
</div>
<div style="margin-bottom: 40px">
<h5>II. Assumption of Risk</h5>
<p style="margin-top: 20px;">I agree that I am responsible for my safety while participating in this Race. I assume all risks of running or walking along roadways. I voluntarily assume all risks, known and unknown, seen and unforeseen, arising from my participation in the Race. </p>
</div>
<div style="margin-bottom: 40px">
<h5>III. Waiver and Release</h5>
<p style="margin-top: 20px;">Being aware of the risks and willing to assume them, I waive, release, hold harmless and forever discharge all organizations, agents and individuals associated with the Race, including but not limited to the State of Vermont, the Vermont Governor's Council on Physical Fitness and Sports, the Race organizing committee, sponsors, volunteers, and anyone connected with the Race, from all claims, liabilities, demands, or rights of any kind, including but not limited to those arising from negligence on the part of any of the aforementioned persons or entities, for any loss, damage or injury to me or my property, or for damage caused by me or by anyone else (including Acts of God), arising from my participation in the Race. I intend for this waiver and release to bind my relatives, heirs, personal representatives, beneficiaries, next of kin and assigns.</p>
</div>
<div style="margin-bottom: 40px">
<h5>IV. Photograph Permission</h5>
<p style="margin-top: 20px;">I further grant permission for my photographic or video image to be used on the Race website or the website of the Vermont Governor's Council on Physical Fitness and Sports. <b style="color: red";> **Race participants must be at least 16 years old on race day. If participant is under 18 but at least 16, parent must sign below in the appropriate section instead of participant.</b></p>
</div>
<div class="row">
<form id="contactForm" action="<?php echo base_url()."home/accept_waiver_code"?>" class="contact-form" method="post" role="form">
<div class="col-md-6">
<div class="form-group">
<label class="control-label" for="first_name"><?php _e("First Name"); ?></label>
<input value="<?php echo $first_name;?>" style="background-color: #eee; !important" id="first_name" type="text" maxlength="100" name="first_name" class="form-control" placeholder="First Name *" required="required" data-error="First Name is required." disabled>
<div class="help-block with-errors"></div>
</div>
<div class="form-group">
<label class="control-label" for="last_name"><?php _e("Last Name"); ?></label>
<input value="<?php echo $last_name;?>" style="background-color: #eee; !important" id="last_name" type="text" maxlength="100" name="last_name" class="form-control" placeholder="Last Name *" required="required" data-error="Last Name is required." disabled>
<div class="help-block with-errors"></div>
</div>
<div class="form-group">
<label class="control-label" for="last_name"><?php _e("IP Address"); ?></label>
<input value="<?php echo $ip_add;?>" style="background-color: #eee; !important" id="last_name" type="text" maxlength="100" name="last_name" class="form-control" placeholder="Last Name *" required="required" data-error="Last Name is required." disabled>
<div class="help-block with-errors"></div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="control-label" for="last_name"><?php _e("Date and Time"); ?></label>
<input value="<?php echo $date_time;?>" style="background-color: #eee; !important" id="last_name" type="text" maxlength="100" name="last_name" class="form-control" placeholder="Last Name *" required="required" data-error="Last Name is required." disabled>
<div class="help-block with-errors"></div>
</div>
<div class="form-group">
<label class="control-label" for="e_sign"><?php _e("Typed Electronic Signature"); ?></label>
<input id="e_sign" type="text" maxlength="100" name="e_sign" class="form-control" placeholder="Electronic Signature *" required="required" data-error="Electronic Signature is required.">
<div class="help-block with-errors"></div>
</div>
<div class="form-group">
<label class="control-label" for="last_name">
<input type="checkbox" name="check_box_waiver" required="required" data-error="Please Check the input box."> 
<?php _e(" I have read this agreement carefully and understand that this agreement is a binding promise. In consideration of your acceptance of my entry fee, I hereby sign this document voluntarily."); ?>
</label>
<div class="help-block with-errors"></div>
</div>
</div>
<div class="col-md-12" style="text-align: center;">
<input type="hidden" name="rid" id="rid" value="<?php echo $rid;?>">
<input type="submit" id="submit_btn" class="btn btn-primary" value="Submit">
</div>
</form>
</div>
</div>
</div>
</div>
</div>
</section>
<script>
$(document).ready(function(){
$('#contactForm').validator();
});
$('#contactForm').submit(function() {
});
</script>