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WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

  1. YiPoA offers a wide range of activities, which may include the following or similar activities:

    Games with balls, Laser tag, Bubble balls, Bounce zones, Gaga ball, Inflatable obstacles, Dodgeball, Inflatable jousting, Inflatable boxing, Archery tag, Skateboards, Bikes, Trikes

    In consideration of the opportunity to participate in any activities offered by YiPoA, I ACKNOWLEDGE THAT THE ACTIVITIES OFFERED ARE INHERENTLY DANGEROUS AND THAT UNUSUAL RISKS AND HAZARDS ARE CONNECTED WITH THESE ACTIVITIES, AND I HEREBY ASSUME THE RISKS OF ALL OF THESE ACTIVITIES, as well as the general risks inherent in physical activity.  I hereby elect to voluntarily participate in these and other activities with full knowledge that said activities may be hazardous to me and my property, including sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage, 

  2. I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE YiPoA, its officers, agents, servants, volunteers, or employees (hereinafter the RELEASEES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in activities offered by the Releasees or while in, on or upon the premises where the activity is being conducted. 
  3. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any of the property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in activities offered by the Releasees, or while in, on or upon the premises where the activity is being conducted, and I assume all financial responsibility for medical treatment rendered to me as a result of any injury sustained by me in the course of the activities. 
  4. I AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage or costs, including court costs and attorney fees, that they may incur due to my participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise, or from use of my likeness as set forth below.
  5. It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above-named RELEASEES.  I further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Missouri. I agree that any dispute over this agreement or claim shall be resolved through a mutually acceptable alternative resolution process, and if such a process cannot be agreed, then such dispute will be submitted to a three-member arbitration panel pursuant to the rules of the American Arbitration Association.
  6. I ACKNOWLEDGE AND REPRESENT THAT I HAVE READ THE FOREGOING WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT, UNDERSTAND IT AND SIGN IT VOLUNTARILY AS MY OWN FREE ACT AND DEED; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for the full, adequate and complete consideration of being allowed to enter the premises and participate in activities thereon, fully intending to be bound by same.
  7. BY INITIALING BELOW THIS PARAGRAPH, I grant permission to use the Participant’s likeness in photograph, video or other digital media and to edit, alter, copy, exhibit, publish or distribution such likeness for any lawful purpose.  I waive the right to inspect or approve any final product and waive any right to royalties or other compensation arising from or related to the use of the likeness. I understand that any photograph, video or other digital media that uses my likeness will be the property of YiPoA and will not be returned.  PLEASE INITIAL BELOW.

Date: September 19, 2018

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
If Participant is under the age of 18, Parent/Guardian consents to the minor’s participation in the activities offered by YiPoA, agrees to all terms, agreements and covenants above on behalf of the Participant and Parent/Guardian, consents for YiPoA to seek reasonable and necessary medical treatment for Participant during such event or associated activities, and agrees to be responsible for any cost of such treatment.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Verbal Confirmation
Was there a verbal confirmation received from the parent or guardian?*
No
Yes

YiPoA Verbal Confirmation Witness
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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