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Play waivers are required for every infant, toddler & youth on The Urban Chalkboard premises.

Waivers are valid for 1 year and only need to be completed & signed once every 12 months.

 

In exchange for The Urban Chalkboard allowing my child (“Child”) to participate in activities (“Activities”) I agree to the following:

1. Voluntary Participation. I understand and confirm that I am voluntarily allowing my Child to participate in the Activities.

2. Identification of Risks. I understand my Child’s participation in the Activities may involve risk of injury and loss, both to person and property. I also understand the risk of injury to my Child may include the possibility of permanent disability and death. I understand this Waiver and Release is intended to address all risks arising out of or relating to my Child’s participation in the Activities, including risks created by actions, inactions, or negligence on the part of The Urban Chalkboard or its members, managers, officers, employees, agents, volunteers, successors, or assigns (collectively, the “Representatives”), and that these risks, may include, but are not limited to, risks created by the following:

The use and condition of The Urban Chalkboard’s premises, facilities, and equipment;
 
The lack or inadequacy of policies, rules, regulations, or supervision for the Activities;
 
The failure of The Urban Chalkboard or its Representatives to foresee or to protect me or my Child from actions, inactions, or negligence of any person, or the recklessness, intentional, or criminal misconduct of persons other than those affiliated with The Urban Chalkboard; and
 
The inadequacy or unavailability of medical facilities or treatment.

 

3. Assumption of Risk. On behalf of my Child and myself, I assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected with my Child’s participation in the Activities, and I accept personal responsibility for any liability, injury, loss, or damage in any way connected with my Child’s participation in the Activities.

Caregivers proxy on behalf of the parent and assume the same level of responsibility for participating children.

Caregivers are responsible for providing parent contact info (email/phone) and/or forwarding all signed waivers & receipts on parent(s) behalf.


4. Release and Waiver. On behalf of my Child and myself, I release The Urban Chalkboard and its Representatives from any and all liability, and waive any and all claims, for liability, injury, loss, damage, or expense, including attorneys’ fees, in any way connected with my Child’s participation in the Activities, whether or not caused in whole or in part by the negligence or other misconduct of The Urban Chalkboard or its Representatives (a “Claim”).

5. Indemnification. I agree to indemnify and to hold harmless The Urban Chalkboard and its Representatives from any Claim or expense, including attorneys’ fees (including the cost of defending any Claim I might make, or that might be made on my behalf, that is released or waived hereby), in any way connected with a Claim.

6. Binding Effect. This instrument shall be binding upon my Child, relatives, next of kin, personal representatives, heirs, beneficiaries, and assigns, and me, and inure to the benefit of The Urban Chalkboard and its Representatives.

7. Medical Treatment. I authorize The Urban Chalkboard and its Representatives to provide my Child, through medical personnel of their choice, customary medical assistance, transportation, and emergency medical services should my Child require such assistance, transportation, or services due to injury or damage related to the Activities. This does not impose upon The Urban Chalkboard or its Representatives to provide such assistance, transportation, or services.

8. Severability. If any provision of this Waiver and Release is held to be invalid or unenforceable, such invalidity or unenforceability shall not otherwise affect any other provision of this instrument.

9. Applicable Law. This instrument shall be governed in accordance with the law of the State of Indiana.

10. Use of Likeness. On behalf of myself and my Child, I grant to The Urban Chalkboard an unrestricted, perpetual, irrevocable, non-royalty bearing, and transferable right and license to use, transmit, distribute, display, and otherwise utilize my Child’s image and/or likeness, as captured, photographed, or otherwise memorialized in connection with the Activities, in any medium or format, for any purpose whatsoever. To opt-out of photos inform the front desk when checking in to the cafe.

11. No Outside Food or Drinks. Snacks & drinks are available for purchase. We also offer a full-service cafe with your favorite coffee, tea & espresso drinks. The Urban Chalkboard reserves the right to refuse entry to anyone not adhereing to this policy.

12. Weapons. We respectfully request that customers not carry weapons into our cafe, studio or outdoor seating area unless they are authorized law enforcement personnel. 

Choose Adult & Minor(s) then select the number infants & children under the age of 18 to include on this waiver...
AdultAdult and Minor(s)
1 Minor2 Minors3 Minors4 Minors5 MinorsMore Minors6 Minors7 Minors8 Minors9 Minors10 Minors
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First Children Name

First Name*

Last Name*
First Children Date of Birth*
First Children additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
First Children Signature*
Second Children Name

First Name*

Last Name*
Second Children Date of Birth*
Second Children additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
Third Children Name

First Name*

Last Name*
Third Children Date of Birth*
Third Children additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
Fourth Children Name

First Name*

Last Name*
Fourth Children Date of Birth*
Fourth Children additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
Fifth Children Name

First Name*

Last Name*
Fifth Children Date of Birth*
Fifth Children additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
Sixth Children Name

First Name*

Last Name*
Sixth Children Date of Birth*
Sixth Children additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
Seventh Children Name

First Name*

Last Name*
Seventh Children Date of Birth*
Seventh Children additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
Eighth Children Name

First Name*

Last Name*
Eighth Children Date of Birth*
Eighth Children additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
Ninth Children Name

First Name*

Last Name*
Ninth Children Date of Birth*
Ninth Children additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
Tenth Children Name

First Name*

Last Name*
Tenth Children Date of Birth*
Tenth Children additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
Signing Adult Email Address

Email*

Confirm Email*
Check to get upcoming event & program announcements
How did you first hear The Urban Chalkboard?
Facebook
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Google
Yelp
Indy With Kids
Indy's Child
theCityMoms
Friend or Family

Other- please describe
The more you know...

WiFi password is available on the large chalkboard above our velcro wall


No outside food or drinks

All children must play in socks

Only non-walking children under 18 months allowed in padded baby area
Signing Adult Information

Help us decide on our next location by providing your zip code?

What is your relationship to the child(ren) included in this waiver*

If you are not the parent or guardian provide first & last name of parent or guardian
Opt-out of photos. Notify front desk, upon arrival, of your preference.
No Photos Please
Signing Adult Name

First Name*

Last Name*
Signing Adult Date of Birth*
Signing Adult additional info

Allergy or Health Notes- DO NOT TYPE ANYTHING IN THIS BOX IF NONE
Signing Adult 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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