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BARTLESVILLE GYMNASTICS CLUB ACTIVITIES RELEASE WAIVER


BARTLESVILLE GYMNASTICS CLUB WELLNESS RELEASE, WIAVER OF LIABILITY, AND INDEMNIFICATION AGREEMENT


In consideration for Bartlesville Gymnastics Club allowing my and/or my minor’s use of the Bartlesville Gymnastics Club Facility, its exercise programs, activities, and other services (collectively Facility), I, the undersigned, fully understand and agree to assume the sole risk of such use. Accordingly, I, on behalf of myself, spouse, heirs, estate, and assigns, expressly agree to release and hold harmless Bartlesville Gymnastics Club , and any of its present, former, or future subsidiaries, divisions, and affiliates, and its and their respective directors, officers, employees, contractors, agents, heirs, legal successors and assigns (collectively Released Parties) from and against any and all claims, suits, demands, losses, damages, expenses, or liability arising under any cause, or claimed under any theory of law, that may arise from any property damage or loss, injury, illness, or death, including that which may result to me and/or my minor, during or arising in any way from my and/or my minor’s use of the Facility, including but not limited to, any such claims arising from the negligence (whether active or passive, sole or concurrent) of any of the Released Parties.


I understand and agree that it is my responsibility to assess the hazards presented by use of the Facility, and further agree that I am the ultimate judge as to whether I and/or my minor can use the Facility without risk or injury to us.


If a medical clearance must be obtained prior to my and/or my minor’s use of the Facility, I agree to consult a physician and obtain written permission prior to use of the Facility.


I agree that I am responsible for monitoring my and my minor’s condition during use of the Facility, and if any symptoms occur, my minor or I will cease such use and seek assistance immediately.


I understand that use of the Facility is voluntary and is not a requirement of Phillips 66.


By signing this Release and Waiver of Liability, I affirm that I have read this form in its entirety, that I understand its content, and that I am signing it voluntarily. I also affirm that my questions regarding the Facility have been answered to my satisfaction.


COMPLETE FOR MINOR DEPENDENTS ONLY:


Indemnification for Minor: The undersigned parent or guardian further agrees to indemnify, save and hold harmless the Released Parties from and against any and all claims, suits, demands, losses, damages, expenses, or liability arising under any cause, or claimed under any theory of law, that may arise from any property damage or loss, injury, illness, or death, that may brought, alleged or incurred by or on behalf of the minor and during or arising in any way from the minor’s use of the Facility, including but not limited to, any such claims arising from the negligence (whether active or passive, sole or concurrent) of any of the Released Parties.


First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 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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