WAIVER OF CIVIL AND CRIMINAL LIABILITY I,__________________________________________, do, hereby, state my informed consent and authorize Kathy L. Renbarger, or her designated associate, to do the following: _____1) Take me into physical custody. _____2) Perform a search of my person and property, for weapons and / or prohibited items (on the understanding that any items which are taken from me shall be returned to me upon my release, with the exception of any illegal drugs, which will be turned over to the police for analysis.) _____3) Transport me and prevent me from leaving a specified area for a period not to exceed 96 hours. _____4) Take charge of any prescribed medications I have in my possession and dispense these to me according to the directions on the label. _____5) Assign me written and oral projects, related to the actions which resulted in my signing this waiver. _____6) Designate a specific number of lashes as a "sentence" for the actions which resulted in my signing this waiver. _____7) At such time she/he/they see fit, either I will handcuff myself or have handcuffs affixed to my wrists; then, I will be securely attached by my wrists and ankles to a steel, inclined frame. _____8) Remove my shirt, if I have not previously removed it. _____9) Scrub my back with rubbiing alcohol, betadine, or a combination of the two. _____10) Apply the designated number of lashes to my bare back, using a whip constructed of 4, two and one half foot lengths of SPT-3, 14/2, flat landscaping cord. _____11) Apply any needed first aid. _____12) I also authorize the videotaping of items 7 through 10, for purposes of the further documentation of my consent for training staff, and illustrating this form of punishment to attornies and judges. I certify that I fully understand that I am giving my consent to an extremely painful form of punishment and I assume all risks and responsibility for this decision. I waive all rights to civil or criminal recourse and agree to hold Kathy L. Renbarger, or any representative thereof, harmless for any such claims or charges which might, otherwise, arise out of the above mentioned items being done to me, including; but, not limited to: claims for any mental, physical, emotional, and / or other damages that might result, kidnapping, false imprisonment, assault and/or battery, any form of wrongful death actions or charges, etc. I further certify that I am mentally competent to sign this document and that I choose to do so without threat, duress or coercion. ________________________________ __________________________________ Notarized Signature Notarization of Signature ________________________________ Final Signature WAIVER OF CIVIL AND CRIMINAL LIABILITY I,__________________________________________, do, hereby, state my informed consent and authorize Kathy L. Renbarger, or her designated associate, to do the following: _____1) Take me into physical custody. _____2) Perform a search of my person and property, for weapons and / or prohibited items (on the understanding that any items which are taken from me shall be returned to me upon my release, with the exception of any illegal drugs, which will be turned over to the police for analysis.) _____3) Transport me and prevent me from leaving a specified area for a period not to exceed 72 hours. _____4) Take charge of any prescribed medications I have in my possession and dispense these to me according to the directions on the label. _____5) Assign me written and oral projects, related to the actions which resulted in my signing this waiver. _____6) Designate a specific number of lashes as a "sentence" for the actions which resulted in my signing this waiver. _____7) At such time she/he/they see fit, either I will handcuff myself or have handcuffs affixed to my wrists; then, I will be securely attached by my wrists and ankles to a steel, inclined frame. _____8) Remove my shirt, if I have not previously removed it. _____9) Scrub my back with rubbiing alcohol, betadine, or a combination of the two. _____10) Apply the designated number of lashes to my bare back, using a whip constructed of 4, two and one half foot lengths of SPT-3, 14/2, flat landscaping cord. _____11) Apply any needed first aid. _____12) I also authorize the videotaping of items 7 through 10, for purposes of the further documentation of my consent, for training staff, and illustrating this form of punishment to attornies and judges. I certify that I fully understand that I am giving my consent to an extremely painful form of punishment and I assume all risks and responsibility for this decision. I waive all rights to civil or criminal recourse and agree to hold Kathy L. Renbarger, or any representative thereof, harmless for any such claims or charges which might, otherwise, arise out of the above mentioned items being done to me, including; but, not limited to: claims for any mental, physical, emotional, and / or other damages that might result, kidnapping, false imprisonment, assault and/or battery, any form of wrongful death actions or charges, etc. I further certify that I am mentally competent to sign this document and that I choose to do so without threat, duress or coercion. __________________________________ _______________________________ Signature (Notarized) Final Signature __________________________________ Signature of Witness/Notary WAIVER OF CIVIL AND CRIMINAL LIABILITY I,__________________________________________, do, hereby, state my informed consent and authorize Kathy L. Renbarger, or her designated associate, to do the following: _____1) Take me into physical custody. _____2) Perform a search of my person and property, for weapons and / or prohibited items (on the understanding that any items which are taken from me shall be returned to me upon my release, with the exception of any illegal drugs, which will be turned over to the police for analysis.) _____3) Transport me and prevent me from leaving a specified area for a period not to exceed 72 hours. _____4) Take charge of any prescribed medications I have in my possession and dispense these to me according to the directions on the label. _____5) Assign me written and oral projects, related to the actions which resulted in my signing this waiver. _____6) Designate a specific number of lashes as a "sentence" for the actions which resulted in my signing this waiver. _____7) At such time she/he/they see fit, either I will handcuff myself or have handcuffs affixed to my wrists; then, I will be securely attached by my wrists and ankles to a steel, inclined frame. _____8) Remove my shirt, if I have not previously removed it. _____9) Scrub my back with rubbiing alcohol, betadine, or a combination of the two. _____10) Apply the designated number of lashes to my bare back, using a whip constructed of 4, two and one half foot lengths of SPT-3, 14/2, flat landscaping cord. _____11) Apply any needed first aid. _____12) I also authorize the videotaping of items 7 through 10, for purposes of the further documentation of my consent for training staff, and illustrating this form of punishment to attornies and judges. I certify that I fully understand that I am giving my consent to an extremely painful form of punishment and I assume all risks and responsibility for this decision. I waive all rights to civil or criminal recourse and agree to hold Kathy L. Renbarger, or any representative thereof, harmless for any such claims or charges which might, otherwise, arise out of the above mentioned items being done to me, including; but, not limited to: claims for any mental, physical, emotional, and / or other damages that might result, kidnapping, false imprisonment, assault and/or battery, any form of wrongful death actions or charges, etc. I further certify that I am mentally competent to sign this document and that I choose to do so without threat, duress or coercion. ________________________________ __________________________________ Notarized Signature Notarization of Signature ________________________________ Final Signature