ONLINE PRIVACY POLICY - June 4, 2018

INTRODUCTION

Questions. This website is owned and operated by ASCEND Pittsburgh. If you have any questions or concerns about our Privacy Policy, feel free to email us at info@ascendpgh.com or contact us by mail at the following address:

ASCEND Pittsburgh, 2141 Mary St., Pittsburgh, PA 15203

Scope. This Privacy Policy applies only to information we collect through electronic or digital means, including our website located at www.ascendpgh.com, certain affiliated sites accessible through this website, our mobile website, and mobile applications, our social media pages and other electronic and digital means of communication (collectively referred to in this Policy as our “Digital Properties”). Unless disclosed otherwise, our affiliated sites are governed by this Privacy Policy.

Our Digital Properties also contain links to third party sites that are not owned or controlled by ASCEND Pittsburgh. Please be aware that we are not responsible for the privacy practices of such other sites. We encourage you to be aware when you leave our Digital Properties and to read the privacy statements of each and every website that collects personally identifiable information.

No Information From Children Under Age 13.  If you are under the age of 13, please do not attempt to register at ASCEND Pittsburgh or provide any personally identifiable information about yourself to us. If we learn that we have collected personally identifiable information from a child under the age of 13, without a parent’s consent, we will promptly delete that information. If you believe we might have any information from a child under the age of 13, please email us at info@ascendpgh.com, or contact us by mail at the following address:

ASCEND Pittsburgh, 2141 Mary St. Pittsburgh, PA 15203

Terms of Use. Please note that your use of our Digital Properties is also subject to our Terms of Use, or other applicable End User License Agreements associated with such Digital Properties.

INFORMATION WE COLLECT

Information You Provide Us. You can provide information to us through various means using our Digital Properties.

The information we collect includes personally identifiable information, such as your name, home address, billing address, shipping address, telephone number, and email address, and social media account ID. You may also provide non-personally identifiable information, for example, demographic information, such as gender and date of birth, or the name of your employer or school. You can also provide demographic information, such as gender and date of birth.

The information we collect may include the following:

Name
Home address
Home / mobile telephone number
Work telephone number
Email address
Gender
Date of birth
Credit, debit or other payment account number and related information and employment verification
Social media account ID
For corporate sponsored program participants: Name of Employer
For school-related programs: name of School or Group
For children enrolled in Youth Rec Programs: we collect from the parent/legal guardian, the name, date of birth, parent/legal guardian contact information, list of known allergies, and physical description (hair and eye color)

During the online account creation process you will select a user name and password. If you purchase any products or services through our Digital Properties we collect your credit card or debit card number and related information, as applicable. For retail online accounts, we maintain your order status, order history and other information through your Rock Gym Pro account.

We collect information from you when you purchase a membership and other services from us, including when you use our mobile app to purchase a membership and other services. If you sign up for a free day pass to our gym, you will provide us your name, email address and telephone number, as well as non-personally identifiable information including your birthdate.

Log Information We Collect from You Automatically. We collect certain information automatically as you use our Digital Properties, including your IP (Internet Protocol) address, browser type, computer type, type of mobile device (if used), the carrier for your mobile device, your computer operating system, the version of the Digital Properties that you access, the site from where you navigated to our Digital Properties, time and date of using the Digital Properties, whether you are a repeat visitor, how long you use the Digital Properties and the pages on or using our Digital Properties that you view. This information is anonymous, and we do not link it to your personally identifiable information.

Cookies. When you visit or use our Digital Properties we send one or more “cookies” to your computer or other device. A cookie is a small file containing a string of characters that is sent to your computer when you visit a website. When you visit the website again, the cookie allows that site to recognize your browser. Cookies may store unique identifiers, user preferences and other information. You can reset your browser to refuse all cookies or to indicate when a cookie is being sent. However, some website features or services may not function properly without cookies. We use cookies to improve the quality of our service, including for storing user preferences, tracking user trends and providing relevant advertising to you.

Pixel Tags. We may use "pixel tags," which are small graphic files that allow us to monitor the use of our websites. A pixel tag can collect information such as the IP address of the computer that downloaded the page on which the tag appears; the URL of the page on which the pixel tag appears; the time the page containing the pixel tag was viewed; the type of browser that fetched the pixel tag; and the identification number of any cookie on the computer previously placed by that server. When corresponding with you via HTML capable email, we may use "format sensing" technology, which allows pixel tags to let us know whether you received and opened our email.

Physical Location. We may collect the physical location of your device by, for example, using satellite, cell phone tower, WiFi signals or your IP address. We may use your device’s physical location to provide you with location-based services and content. We may also share your device’s physical location, combined with information about what advertisements you viewed and other information we collect, with our marketing service providers to enable them to provide you with more localized content and to study the effectiveness of advertising campaigns. You may be able to allow or deny such uses and/or sharing of your device’s location by changing your device’s location settings, but if you choose to deny such uses and/or sharing, we and our marketing service providers may not be able to provide you with the location-based services and content.

Aggregated Information. We may aggregate personally identifiable information. Aggregated information is not personally identifiable information because it does not identify and is not associated with you or any other user of our Digital Properties.

HOW WE USE YOUR INFORMATION

To Provide Products, Services, and Information. As described above, we collect information from you so that we can provide products and services that you purchase using the Digital Properties and information that you request from us.

We use your personally identifiable information to:

Set-up your membership
Provide services and products to you
Process payments for your membership and services, including credit card, debit card and bank account debit (ACH) transactions
Contact you regarding your membership and services, and other administrative information
Respond to your inquiries, comments, reviews and ratings

Retail Online Account. When you create an online account for retail purchases, you can store your personally identifiable information and use it later when using our Digital Properties or purchasing products on or using our Digital Properties. You can also view your current orders and order history.

Newsletters. If you sign-up to receive newsletters or other communications from us, we use your email address and other relevant personally identifiable information to provide the newsletters and other communications to you. You can always opt-out of receiving email newsletters or advertisements by using the opt-out feature provided with the email communications.

Advertising. We use your information to provide advertisements and promotional information relating to products and services that we provide or otherwise offer for sale. We use cookies to track your activity on our Digital Properties so we can provide this advertising to you.
Our Business Purposes. We may use your information for our business purposes, such as data analysis, audits, fraud monitoring and prevention, developing new products and services, enhancing, improving or modifying our Digital Properties, identifying usage trends, determining the effectiveness of our promotional campaigns and operating and expanding our business activities.

Other Purposes. We may use non-personally identifiable information for any purpose, except where we are required to do otherwise under applicable law. In some instances, we may combine non-personally identifiable information with personally identifiable information (such as associating your name with your employer if you are a participant in a corporate sponsored program), in which case we will treat the combined information as personally identifiable information as long as it is combined.

HOW WE SHARE YOUR INFORMATION

Our Third Party Service Providers. We may share your information with our third party service providers and agents who provide services such as website hosting, data analysis, payment processing, order fulfillment, information technology and related infrastructure provision, customer service, email delivery, text messaging, credit card or other payment account processing, auditing and similar services. Contracts with our service providers require them to keep information confidential.
 

Advertising and Third Party Advertisers. We may use third party service providers to display ads on our behalf on our Digital Properties and third party sites not affiliated with ASCEND Pittsburgh. If you view a web page where our ads appear, the advertising company may place a cookie on your computer or use a Web beacon to access a cookie that they previously placed on your computer. These companies do not collect information that can personally identify you, but they may use information about your visits to our Digital Properties and other websites to measure the effectiveness of ads. We do not disclose any personally identifiable information to these companies. We may share aggregate Digital Properties usage information with third party advertisers and partners for the purpose of effectively targeting our online advertisements. Unless you are previously notified, these advertising companies do not link any online behavior or cookies with other information that can be used to personally identify you, such as your name, address, telephone number or email address.

These third party advertising networks also track visitors’ online usage and behavior patterns. These companies may use information about your visits to our Digital Properties and other websites in order to provide advertisements on our Digital Properties and other sites about goods and services that may be of interest to you. The result of these efforts is the creation of an online profile that attempts to predict individual user interests, preferences and purchasing habits. The third party advertising networks then accordingly customize the advertising content served to users when visiting other websites.

At this time we do not respond to browser 'do not track' signals, as we await the work of interested stakeholders and others to develop standards for how such signals should be interpreted. Third parties, including our service providers, may collect information about your online activities over time and across different Web sites, including when you visit our Web site. You can learn about how to exercise choice regarding the collection of information about your online activities over time and across third-party Web sites or online services by visiting www.aboutads.info.

The Digital Advertising Alliance (DAA) is a self-regulatory organization that provides educational content and opt-out tools to help Internet users learn about and address online interest-based behavioral marketing practices. For more information please visit the DAA website athttp://www.aboutads.info.

Legal Requests or Requirements and to Prevent Harm. We reserve the right to disclose your personally identifiable information as required by law and when we believe that disclosure is necessary to protect our rights and/or to comply with a judicial proceeding, court order, or legal process served on our Digital Properties. We may also share information when we have a good faith belief it is necessary to prevent fraud or other illegal activity, to prevent imminent bodily harm, or to prevent harm to ASCEND Pittsburgh, the Digital Properties, our members or other individuals. This may include sharing information with other companies, lawyers, courts, or other government entities.

Sharing by You. If you post comments, information or other materials on our message boards, blogs, social media pages or other services, please note that any information you post or disclose through these services will become public information and may be available to users of the Digital Properties and to the general public. We urge you to be very careful when deciding to disclose your personally identifiable information, or any other information, on the Digital Properties.

Transfer in the Event of Sale or Change of Control. If the ownership of all or substantially all of our business changes or we otherwise transfer assets relating to our business or the Digital Properties to a third party, we may transfer your personally identifiable information to the new owner to be used consistent with this Privacy Policy.

Other Sharing of Non-Personally Identifiable Information. We may share non-personally identifiable information with third parties for any purpose, except where we are required to do otherwise under applicable law. In some instances, we may combine non-personally identifiable information with personally identifiable information (such as associating your name with your employer if you are a participant in a corporate sponsored program), in which case we will treat the combined information as personally identifiable information as long as it is combined.

ACCESS TO YOUR INFORMATION AND CHOICES

You can access and update certain information we have relating to your online account by signing into your account and going to the member information area of our Digital Properties. If you have questions about personally identifiable information we have about you or need to update your information, you can email us at info@ascendpgh.com, or contact us by mail at the following address:

ASCEND Pittsburgh, 2141 Mary St., Pittsburgh, PA 15203

You can opt-out of receiving marketing and promotional emails from ASCEND Pittsburgh by using the opt-out or unsubscribe feature contained in the e-mails. To opt-out of other means of marketing communications, including telephone, text or other electronic communications from ASCEND Pittsburgh, contact a manager at the front desk. You can close your online retail shopping account by contacting us. If you close your account, we will no longer use your online account information or share it with third parties. We may, however, retain a copy of the information for archival purposes, and to avoid identity theft or fraud.

We will try to comply with your request(s) as soon as reasonably practicable. If you opt-out of receiving marketing-related messages from us, we may still send you administrative messages so that you continue to receive important information (for example, transactional messages relating to your membership, purchases and club information).

SECURITY OF YOUR INFORMATION

We use industry standard physical, technical and administrative security measures to protect your information. Our employees have access to your personally identifiable information only on a need to know basis. Contracts with our third party service providers require them to keep information confidential. Sensitive data (such as a credit card number) is protected by SSL encryption when it is transmitted between your web browser and our Digital Properties. However, no data transmission or storage system can be guaranteed to be 100% secure. If you have reason to believe that your interaction with us is no longer secure (for example, if you feel that the security of any account you might have with us has been compromised), please immediately notify us of the problem by contacting us in accordance with the “Questions” section above.

Please note that emails you send to us through our Digital Properties are not encrypted, and we strongly advise you not to communicate any confidential information through these means.

CHANGES TO OUR PRIVACY POLICY

If we decide to change our Privacy Policy, we will post those changes to the Privacy Policy on our homepage, and other places we deem appropriate so that you are aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. We reserve the right to modify this Privacy Policy at any time, so please review it frequently. Any changes to this Privacy Policy will become effective when we post the revised Privacy Policy on our Digital Properties. Your use of the Digital Properties following these changes means that you accept the revised Privacy Policy.

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ACKNOWLEDGMENT AND ASSUMPTION OF RISKS & RELEASE AND INDEMNITY AGREEMENT

 


Review ASCEND's Privacy Policy

All participants and visitors must fill out and sign this Agreement. For participants under 18 years of age, a parent or guardian must also sign this Agreement.

INTRODUCTION.Please read this Acknowledgment and Assumption of Risks & Release and Indemnity Agreement (this “Agreement”) carefully before signing. This Agreement informs you about your responsibilities and assumption of risks, and includes a release of liability, indemnification and surrender of certain legal rights.

Parent(s) or Legal Guardian(s) (hereafter collectively “Parent(s)”) of any participant under the age of 18 (hereafter sometimes “minor” or “child”) shall sign this Agreement. “I,” “me” or other first person references shall include both the Parent(s) and the minor, unless the context requires otherwise. References to “Participant” include both minor and adult participants.

In consideration of the services of Ascend Climbing LLC dba Ascend Pittsburgh (“Ascend”), its agents, owners, officers, directors, employees, representatives, landlords, tenants, partners, joint venturers, and all other persons or entities associated with any of the foregoing (all of the foregoing parties, including without limitation Ascend Climbing LLC dba Ascend Pittsburgh, are collectively referred to hereinafter as the “Released Parties”), and in consideration for the opportunity to enter upon Ascend’s indoor rock climbing facility located at 2141 Mary Street, Pittsburgh, PA 15203 (the “Facility”) and participate in activities at locations, both indoor and outdoor, that are sponsored by or involve any of the Released Parties, I, the undersigned Participant, including Parent(s) or Legal Guardian(s) of minor participants, agree as follows:

ACKNOWLEDGMENT AND ASSUMPTION OF RISKS. Engaging in climbing or other activities at the Facility and/or at other locations, both indoor and outdoor, including those that are sponsored by or involve any of the Released Parties, involve serious risks. These activities vary but can include bouldering (un-roped climbing), climbing, belaying (including the use of auto-belay devices), and rappelling on the Facility’s artificial climbing walls or other walls, equipment, or facilities, with or without Ascend staff present, and other activities such as fitness classes (yoga, cardio, etc.), climbing instructional classes, personal instruction or personal training, and use of rental equipment, weights and/or fitness equipment. I acknowledge that participating in climbing or such other activities involves risks, including but not limited to risks involving physical activity, decision making, equipment failure or misuse, and such other risks and hazards associated with rock climbing activities, use of artificial climbing walls or my presence in the Facility. Some risks are inherent in these activities and cannot be eliminated or reduced. A variety of other risks also exist. I understand that wearing a helmet does not eliminate the dangers associated with any activity but that in certain instances a helmet can reduce the risk of permanent injury or death. I understand that Ascend recommends that I wear a helmet and that if I choose not to wear a helmet I do so against their advice and at my own risk. These inherent and other risks, hazards and dangers can cause injury, property damage, illness, mental or emotional trauma, paralysis, disability or death to participant or others.

I understand that if I choose to exercise or engage in activity at the Facility, there will be periods when my activities are not supervised or directly monitored by Ascend personnel. I understand that climbing, exercise and/or other activities in unsupervised and/or unmonitored settings may increase the risks to me related to the occurrence of adverse events and the provision of timely emergency response.

I understand that known, unknown and/or unanticipated risks, hazards and dangers may result in injury, damage, death or other loss. I acknowledge that participating in these activities requires a special degree of skill and knowledge different from other activities and that I have responsibilities as a participant. I have no mental or physical problems or limitations that might compromise or affect my ability to participate in climbing activities which have not been disclosed in writing to Ascend. I acknowledge that Ascend staff is, and has been, available to answer further questions about the nature and physical demands of these activities and the risks, hazards and dangers associated with these activities. I understand that the presence of Ascend personnel is absolutely no assurance of my safety or the lessening of any of these risks, and I represent I am fully capable of participating in these activities without causing harm to me or others.

I have read or have had the opportunity to read the Rules & Etiquette and other regulations in the Facility and agree to abide by such rules and regulations. I agree to follow all Ascend rules and regulations that may be posted at the Facility or communicated to me by Ascend personnel from time to time. If my access or membership is revoked, suspended or terminated I understand that I am not entitled to a refund.

I understand that neither Ascend nor any of the Released Parties makes any warranties or representations (express or implied) concerning the Facility, including but not limited to my safety or that of my property while on or about the Facility or the conditions of the Facility or the quality of the equipment I may use or encounter while in the Facility or engaging in activities therein.

Climbing is dangerous! In both supervised and unsupervised activities, I acknowledge that all participants are responsible for their own safety. My participation in these activities is purely voluntary, and I choose to participate in spite of and with knowledge of the risks. Therefore, I assume and accept full responsibility for those risks identified here and for those risks not identified, and for injury, damage, death or other loss suffered by me resulting from those risks, my own negligence, and/or the negligence of any one or more of the Released Parties.

RELEASE AND INDEMNITY AGREEMENT. Please read carefully. This section contains a Release and Indemnity Agreement and surrender of certain legal rights. The undersigned agree(s) as follows:

(1) I hereby release, waive, forever discharge, and covenant not to sue the Released Parties, with respect to all losses, damages, expenses, claims, causes of action, or other liabilities (including attorneys’ fees and costs), whether known or unknown, arising out of any injury, damage, death or other loss to me or my child in any way connected with my/my child’s enrollment or participation in activities at the Facility and/or at other locations, both indoor and outdoor, that are sponsored by or involve the Released Parties, use of the Facility’s climbing walls or other equipment or facilities, or my/my child’s presence on or about the Facility. I hereby waive all claims I may have against the Released Parties, and agree that neither I, nor anyone acting on my behalf, will make a claim or file a lawsuit of any kind against any one or more of the Released Parties, as a result of any injury, damage, death or other loss suffered by me or my child regardless of the negligence of any person, including but not limited to the negligence of any one or more of the Released Parties;

(2) I hereby agree to defend and indemnify (“indemnify” meaning protect by reimbursement or payment) and hold each of the Released Parties harmless with respect to all losses, damages, expenses, claims, causes of action, or other liabilities (including attorneys’ fees and costs), whether known or unknown:

(a) Brought by or on behalf of me, my child, or a family member, arising out of any injury, damage, death or other loss to me or my child in any way connected with my/my child’s enrollment or participation in activities at the Facility and/or at other locations, both indoor and outdoor, that are sponsored by or involve the Released Parties, use of the Facility’s climbing walls or other equipment or facilities, or my/my child’s presence on or about the Facility, regardless of the negligence of any person, including but not limited to the negligence of any one or more of the Released Parties; and/or,

(b) Brought by a co-participant or any other person, arising out of any injury, damage, death or other loss claimed to be caused, in whole or in part, by my/my child’s conduct in the course of participating in activities at the Facility and/or at other locations, both indoor and outdoor, that are sponsored by or involve the Released Parties, use of the Facility’s climbing walls or other equipment or facilities, or my/my child’s presence on or about the Facility, regardless of the negligence of any person, including but not limited to the negligence of any one or more of the Released Parties.

This Release and Indemnity Agreement includes any losses claimed to be caused, in whole or in part, by the negligence of any one or more of the Released Parties and includes, but is not limited to, claims for personal injury, property damage, wrongful death, products liability, breach of contract or otherwise.

MISCELLANEOUS. I authorize Ascend staff or any of the Released Parties to obtain or provide medical care for me without liability and to transport me to a medical facility. I authorize medical personnel to render such treatment they deem necessary for my health. I agree that the Released Parties have no responsibility for medical care provided to me and I agree to pay all costs associated with such medical care and transportation.

I authorize Ascend to use any photograph, video or other image of me taken inside the Facility or at any event sponsored by any of the Released Parties to be used in promotional materials, brochures, websites, television, films or such other uses that they deem appropriate and with no compensation to me.

This Agreement shall not constitute an invitation to enter upon the Facility and I acknowledge that I have received only a limited license to enter upon the Facility as a licensee and solely for my own benefit, and the limited license may be amended or revoked at any time by Ascend in its sole and absolute discretion.

I affirm that this Agreement supersedes any and all previous oral or written promises or agreements, and I understand that this is the entire agreement between me and Ascend and that it cannot be modified or changed by any representation or statement(s) by the Released Parties or any agent or employee thereof. This Agreement may only be amended by a written document duly executed by all parties. Any portion of this Agreement deemed unlawful or unenforceable shall not affect the enforceability of the remaining provisions of this Agreement and the remaining provisions shall continue in full force and effect.

I agree that this Agreement and all other aspects of my relationship with the Released Parties are governed by Pennsylvania state law exclusive of its choice of law provisions. Further, any mediation, arbitration, lawsuit, or other proceeding arising out of or relating to my enrollment or participation in Ascend activities, must be filed or entered into only in the Commonwealth of Pennsylvania and Pennsylvania state law shall apply. I agree to attempt to settle any dispute (that cannot be settled by discussion) through mediation before a mutually acceptable mediator.

I VOLUNTARILY WAIVE ANY RIGHT I MAY HAVE TO A TRIAL BY JURY IN ANY ACTION INVOLVING ANY ONE OR MORE OF THE RELEASED PARTIES OR THE FACILITY.

I have carefully read, understand and voluntarily sign this Agreement and acknowledge that it shall be effective and binding upon myself and my family, my heirs, executors, personal representatives, estate, and my successors and assigns.

Date: December 13, 2018 

First Participant or Visitor's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant or Visitor's Date of Birth*
First Participant or Visitor's Info
Gender *
First Participant or Visitor's Signature*
Second Participant or Visitor's Name

First Name*

Middle Name

Last Name*
Second Participant or Visitor's Date of Birth*
Second Participant or Visitor's Info
Gender *
Third Participant or Visitor's Name

First Name*

Middle Name

Last Name*
Third Participant or Visitor's Date of Birth*
Third Participant or Visitor's Info
Gender *
Fourth Participant or Visitor's Name

First Name*

Middle Name

Last Name*
Fourth Participant or Visitor's Date of Birth*
Fourth Participant or Visitor's Info
Gender *
Fifth Participant or Visitor's Name

First Name*

Middle Name

Last Name*
Fifth Participant or Visitor's Date of Birth*
Fifth Participant or Visitor's Info
Gender *
Sixth Participant or Visitor's Name

First Name*

Middle Name

Last Name*
Sixth Participant or Visitor's Date of Birth*
Sixth Participant or Visitor's Info
Gender *
Seventh Participant or Visitor's Name

First Name*

Middle Name

Last Name*
Seventh Participant or Visitor's Date of Birth*
Seventh Participant or Visitor's Info
Gender *
Eighth Participant or Visitor's Name

First Name*

Middle Name

Last Name*
Eighth Participant or Visitor's Date of Birth*
Eighth Participant or Visitor's Info
Gender *
Ninth Participant or Visitor's Name

First Name*

Middle Name

Last Name*
Ninth Participant or Visitor's Date of Birth*
Ninth Participant or Visitor's Info
Gender *
Tenth Participant or Visitor's Name

First Name*

Middle Name

Last Name*
Tenth Participant or Visitor's Date of Birth*
Tenth Participant or Visitor's Info
Gender *
Participant or Visitor'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 this box to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
How did you hear about us?

If the above "How did you hear about us?" answers don't fit the bill, please let us know how you DID hear about us. Thanks!
I am the parent or legal guardian of the above-named individual. I hereby agree to the provisions of the foregoing Agreement and specifically make, enter into, and join each and every acknowledgement, assumption, representation, waiver, release, indemnity (including but not limited to the indemnity set forth in the paragraphs numbered (1) and (2) under the “Release and Indemnity Agreement” heading of this Agreement) and every other agreement described in this Agreement on behalf of myself, and all others claiming through me and, to the extent permitted by law, the minor participant and every other parent or legal guardian of the minor and those claiming by or through the minor. I hereby represent that I have authority to execute this Agreement in such capacity, and I agree personally to indemnify, hold harmless and defend the Released Parties from and against any losses, damages, expenses, claims, causes of action, or other liabilities (including attorneys’ fees and costs), whether known or unknown, arising out of any lack of such authority. I acknowledge that I have carefully read, understand and voluntarily sign the foregoing Agreement. I VOLUNTARILY WAIVE ANY RIGHT I MAY HAVE (OR THAT THE MINOR MAY HAVE) TO A TRIAL BY JURY IN ANY ACTION INVOLVING ANY ONE OR MORE OF THE RELEASED PARTIES OR THE FACILITY.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Info
Gender *
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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