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General Registration and Participation Waiver for Adult with 1 or More Minors

 

 

IMPORTANT: THIS IS A LEGAL DOCUMENT

PLEASE READ AND UNDERSTAND THIS DOCUMENT BEFORE SIGNING

MINOR PARTICIPANT INFORMED CONSENT TO TREATMENT, WAIVER, AND RELEASE FOR LITTLE BEAKERS PROGRAMS AND ACTIVITIES

This agreement must be completed by the Participant and by Parent/Legal Guardian in order to participate in the activities associated with the Little Beakers program. 

 

MINOR PARTICIPANT INFORMED CONSENT

I am the Participant named below. I am familiar with the curriculum and the activities which will take place in the above named program or activity (the "Program") offered through Learning Science Labs 1, LLC dba Little Beakers - Sandy (herein as Company). I understand that my participation can include foreseeable and unforeseeable risks and other hazardous activities inherent in the Program, including but not limited to skin and eye reactions and irritations, which may expose me to illness, injury or death. Knowing of these risks, I freely and voluntarily participate in the Program. 

I am familiar with the rules of conduct, guidelines and Company policies relating to this Program. I agree to utilize all safety equipment and to abide by all of the policies and procedures, including safety policies outlined by the Company and any instructions or directions given to me by an authorized Company employee or representative during the course of the Program.

PARENT/GUARDIAN CONSENT TO TREATMENT, WAIVER AND RELEASE

I am the parent/guardian of the below named participant/s who are under 18 years of age. I am familiar with the curriculum and the activities which will take place in the above named program (the "Program") offered through Learning Science Labs, 1 LLC, doing business as Little Beakers - Sandy (herein as Company) and hereby give consent for the Participant to participate in the Program. I understand that participation in the Program can include foreseeable and unforeseeable risks and other hazardous activities inherent in the program, including, but not limited to skin and eye reactions and irritations, which may expose me and my child(ren) to illness, injury or death. 

I state that Participant/s is/are free from any known heart, respiratory or other health program that could prevent Participant from safely participating in the Program or any of its activities. 

In consideration of my, and all minors' under my care, participation in the Program and activities of Learning Science Labs 1, LLC, doing business as Little Beakers - Sandy (herein as Company), I hereby for myself and my child(ren) and our respective heirs and successors, release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes Company, its members, officers, agents, volunteers, or employees from any and all liabilities, claims, demands, injuries, costs of medical care, or damages, including court costs and attorneys fees and expenses, that may be sustained by my child while participating in the Program and/or its activities or while on the premises of Company, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of Company. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct.

I am familiar with the rules of conduct, guidelines and Company policies relating to this Program. I understand and acknowledge my responsibility to review and ensure that I and Participant/s utilize all safety equpiment and follow the safety guidelines and policies of the Company, as they may change from time to time. The parent assumes the risk for a child left unattended.

I am aware that individual and group publicity photos and videos may be taken in consideration for my child(ren)'s participations and I hereby grant my permission for my child(ren)'s likeness to be used in Company publicity or advertising.

In the event of an injury, accident or emergency I hereby give my express consent and authorize my child to be transported to a hospital or emergency room for medical treatment and authorize Company to obtain for the Participant any necessary medical aid, anesthesia and/or operation, if in the opinion of the attending physician, such treatment is necessary. I hold Company harmless in the execution of such. I certify that Participant has medical insurance and otherwise agree to be personally responsible for any and all costs or medical expenses which may be incurred as a result of any injury related to the Program or sustained while participating at Little Beakers.

If any portion of this Agreement is held to be invalid by a court of law, then it is agreed and intended that all the remainder shall, notwithstanding, continue in full force and effect.

I have read and understand everything contained herein and agree to be so bound. I acknowledge that by this Agreement, I have freely and voluntarily given up certain legal rights and possible claims that I might otherwise assert or maintain against Company, including specifically, but not limited to, rights arising from or claims for the negligent acts or omissions of Company. I assume responsibility and legal liability for the claims or other legal demands, including defense costs, which may be asserted by third parties against me or Participant as a result of Participant's participation in the Program. 

Participant has been advised to maintain health & accident insurane to cover the costs of treatment in the event of any injury or illness. 

First Customer's Name

First Name*

Last Name*
First Customer's Age Acknowledgment*
First Customer's Date of Birth*
I certify that I am 18 years of age or older
First Customer's Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
First Customer's Signature*
Second Customer's Name

First Name*

Last Name*
Second Customer's Date of Birth*
Second Customer's Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
Third Customer's Name

First Name*

Last Name*
Third Customer's Date of Birth*
Third Customer's Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
Fourth Customer's Name

First Name*

Last Name*
Fourth Customer's Date of Birth*
Fourth Customer's Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
Fifth Customer's Name

First Name*

Last Name*
Fifth Customer's Date of Birth*
Fifth Customer's Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
Sixth Customer's Name

First Name*

Last Name*
Sixth Customer's Date of Birth*
Sixth Customer's Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
Seventh Customer's Name

First Name*

Last Name*
Seventh Customer's Date of Birth*
Seventh Customer's Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
Eighth Customer's Name

First Name*

Last Name*
Eighth Customer's Date of Birth*
Eighth Customer's Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
Ninth Customer's Name

First Name*

Last Name*
Ninth Customer's Date of Birth*
Ninth Customer's Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
Tenth Customer's Name

First Name*

Last Name*
Tenth Customer's Date of Birth*
Tenth Customer's Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
Adult Email Address

Email
Check to receive periodic emails about upcoming Little Beakers' events, news and offers.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Contact Phone Number (Please provide if dropping off for camps, parents' nights out, classes, etc.)

Contact Phone Number
Any allergies or conditions we should be aware of?*
No
Yes

Please describe:
From where are you visiting us today and how did you hear about us?
From where are you visiting us today and how did you hear about us? *
Attended Party or Field Trip
City Journal
Friend/Family
Internet Search
Kids-Out-and-About
Utah Kids Club
Other

Zip Code *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Adult Name

First Name*

Last Name*
Adult Age Acknowledgment*
Adult Date of Birth*
I certify that I am 18 years of age or older
Adult Information
Signing adult's relationship to this participant*
Self
Parent or Legal Guardian
Other

If 'Other', type relationship
Adult Signature*
Electronic Signature Consent*
 I understand and acknowledge that by electronically signing this Agreement, I am agreeing to be bound by its terms and conditions. MY ELECTRONIC SIGNATURE INDICATES THAT I HAVE READ THE ENTIRE AGREEMENT, UNDERSTAND THAT IT AFFECTS MY LEGAL RIGHTS, AND UNDERSTAND THAT IT WAIVES MY RIGHT TO SUE COMPANY. By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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