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ANNUAL PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK

Today's Date: December 18, 2018

In consideration of the services of Emerald City Trapeze Arts LLC, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as "ECTA"), I hereby agree to release, indemnify, and discharge ECTA, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I acknowledge that my participation in aerial arts, trapeze, circus skills and other various discisplines entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.

The risks include, among other things: slips and falls; falling from equipment; rope burns; pinches, scrapes, twists and jolts that could result in scratches, bruises, sprains, lacerations, fractures, concussions, or even more severe life threatening hazards; strains, cuts, bruises, muscle soreness and fractures; musculoskeletal injuries including head, neck, and back; injuries to internal organs; the negligence of other people; the negligence of other participants, or other persons who may be present; my own physical condition; and the risk of emotional and psychological injuries or physical damage associated with this activity. Traveling to and from shows, meets and exhibitions raises the possibility of any manner of transportation accidents. In any event, if you or your child is injured, any medical assistance, at your own expense.

Furthermore, ECTA employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant's fitness or abilities. They might misjudge the weather or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction.

2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.

3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless ECTA from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of ECTA 's equipment or facilities, including any such claims which allege negligent acts or omissions of ECTA.

4. Should ECTA or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.

6. In the event that I file a lawsuit against ECTA, I agree to do so solely in the state of Washington, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining document shall remain in full force and effect.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against ECTA on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
First Participant's Signature*
Second Participant's Name

First Name*

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

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
Third Participant's Name

First Name*

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

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
Fourth Participant's Name

First Name*

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

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
Fifth Participant's Name

First Name*

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

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
Sixth Participant's Name

First Name*

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

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
Seventh Participant's Name

First Name*

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

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
Eighth Participant's Name

First Name*

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

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
Ninth Participant's Name

First Name*

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

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
Tenth Participant's Name

First Name*

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

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
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:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
PARENT'S OR GUARDIAN'S ADDITIONAL INDEMNIFICATION (Must be completed for participants under the age of 18): In consideration of "Minor" being permitted by ECTA to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless ECTA from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Who to contact in case of emergency: 


Name: *

Phone: *

Relationship: *
Do you have any conditions for which you are currently receiving treatment?*
No
Yes

If yes, please explain:
Are you currently taking any medication?*
No
Yes

If yes, please list:
Do you have medical insurance?*
No
Yes

If yes, please provide the following insurance information:


Insurance Provider:

Policy Holder:

Relation to Self:

How did you hear about us?
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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