Loading...

Breakout Richmond

9101 Midlothian Turnpike

Suite 700

Richmond, VA 23235

 

TODAY'S DATE: November 16, 2019

WAIVER AND RELEASE OF LIABILITY FORM

I agree and acknowledge as follows:

1. The Breakout Games places you in a room where you and the others in the room will rely upon clues and puzzles to enable you to escape out of the room. Each room contains furniture and objects consistent with the theme of the room. In some rooms, the participants are handcuffed and/or blindfolded. I fully understand and acknowledge that (a) risks and dangers exist in my participation in The Breakout Games; (b) my participation in such activities may be emotionally demanding, create a fear of claustrophobia or result in bodily injury; (c) these risks and dangers may be caused by the negligence of the owners, employees, officers or agents of The Breakout Games, my negligence, the negligence of other participants, the negligence of others, accidents, the forces of nature or other causes. These risks and dangers may arise from foreseeable or unforeseeable causes and by my participation in these activities. I hereby assume all risks and dangers and all responsibility for any losses and/or damages, whether caused in whole or in part by the negligence or other conduct of the owners, agents, officers, employees of The Breakout Games or by any other person.

2. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify The Breakout Games, its affiliates and related companies and their respective directors, managers, owners, officers, successors, assigns, agents, representatives and employees (collectively, the Released Parties) from any and all claims, actions or losses for bodily injury, emotional distress, pain and suffering, property damages, wrongful death, or otherwise which may arise out of my participation in the Breakout Games. I specifically understand that I am releasing, discharging and waiving any claims or actions that I may have now or in the future for the negligence or other conduct by the owners, agents, officers or employees of the Released Parties.

3. I understand that demonstrating inappropriate behavior that interferes with the delivery of the guest experience, including being under the influence of alcohol and/or drugs, may result in me being turned away and my game stated as a no show. 

4. The Released Parties are not responsible or liable for my personal belongings while at The Breakout Games.

5. I give The Breakout Games the right to use any photographs or video recordings created while I participate in The Breakout Games activities for publicity and advertising purposes.

6. I acknowledge that the contact information set forth below is true and accurate.

7. I hereby grant permission for The Breakout Games to store my contact information for operational purposes, unless I grant the permission as set forth below.

First Participant's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Just a little more info
What brought you to Breakout?
Date Night
Adult's Birthday
Family Event
Team Building
Child's Birthday
Friends Event
You're an Escape Game Fanatic
How did you initially hear about Breakout?
Google
Facebook
Instagram
TripAdvisor
Yelp
Friend
Saw the 'Escape Room' movie
Other
How many times have you played Breakout before today?
3+
2
1
0
Parent(s) or 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.
Parent or Guardian's Name

First Name*

Last Name*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver