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Release of Liability, Waiver of Claims, Express Assumption of Risk and Indemnity Agreement

I am the parent/legal guardian of the Child/Children named below or I have obtained permission from the parent/legal guardian of the Child/Children named below to sign this agreement on their behalf. I give permission and accept full responsibility for the Child/Children to participate in the activities at KIDSVILLE PLAYGYM (“Kidsville”). As a Condition to the Child’s/Children’s participation in the activities and by signing this form, I acknowledge and agree that: The operator(s) have advised me that there is GYMNASTICS EQUIPMENT THAT IS DANGEROUS WITHOUT ADULT SUPERVISION; the Child/Children and I are solely responsible for deciding whether or not to participate or to rely upon any instructions, advice, or information regarding the activities; it is not Kidsville’s responsibility to teach safety before, during or after participation and use of the structures; I am solely responsible for the decision to allow the Child/Children to participate and use the structures; I am of legal age and mental competence to knowingly give this acknowledgment and release which shall legally bind me and the Child/Children and our personal representatives, executors, heirs, and assigns. I hereby give permission for myself/my child(ren) to be transported to a medical facility in the case of a medical emergency. I give permission for Kidsville staff to assist my child(ren) in the restroom and/or change his/her diaper if needed. If someone other than the undersigned is to pick up my child(ren) I give Kidsville permission to release my child(ren) to another adult I have appointed. Kidsville will not be held liable for children after they have left the premises.

 
I, the undersigned, give permission for the use of any photos, movies, and audio or video tapings of my child's activities at Kidsville. The material so obtained may be employed with Kidsville's approval for marketing purposes, media coverage or for publicity benefiting our facilities. I HEREBY RELEASE AND WAIVE, ANY AND ALL CLAIMS , KNOWN AND UNKNOWN, THAT THE CHILD/CHILDREN OR I MAY NOW OR LATER HAVE AGAINST KIDSVILLE, ITS MEMBER(S), EMPLOYEE(S), INSTRUCTOR(S), OPERATOR(S) AGENTS, OR REPRESENTATIVES RELATED TO ANY ACT, OMISSION, STATEMENT, OR OCCURRENCE DURING OR RELATED TO THE USE OF THE STRUCTURES OR THE FACILITY, FOR , LIABILITY FOR DIRECT, INDIRECT, VICARIOUS, PUNITIVE AND ANY OTHER DAMAGE WHETHER SUCH PARTY WAS INFORMED OR WAS AWARE OF THE POSSIBILITY OF SUCH LOSS OR DAMAGE. 

First Child Name

First Name*

Last Name*

Phone*
First Child Date of Birth*
First Child Information

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
First Child Signature*
Second Child Name

First Name*

Last Name*
Second Child Date of Birth*
Second Child Information

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
Third Child Name

First Name*

Last Name*
Third Child Date of Birth*
Third Child Information

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
Fourth Child Name

First Name*

Last Name*
Fourth Child Date of Birth*
Fourth Child Information

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
Fifth Child Name

First Name*

Last Name*
Fifth Child Date of Birth*
Fifth Child Information

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
Sixth Child Name

First Name*

Last Name*
Sixth Child Date of Birth*
Sixth Child Information

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
Seventh Child Name

First Name*

Last Name*
Seventh Child Date of Birth*
Seventh Child Information

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
Eighth Child Name

First Name*

Last Name*
Eighth Child Date of Birth*
Eighth Child Information

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
Ninth Child Name

First Name*

Last Name*
Ninth Child Date of Birth*
Ninth Child Information

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
Tenth Child Name

First Name*

Last Name*
Tenth Child Date of Birth*
Tenth Child Information

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
Parent or Guardian's Email Address

Email*
Receive special discounts and info about special events from Kidsville!
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal 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*

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

Other person allowed to pick up children from Kidsville

Phone Number for Authorized Individual
Allergies?*
No
Yes

List of allergies
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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