Loading...

New Guest Registration Form

 

 

ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY, INDEMNITY AGREEMENT (“WAIVER”)

In consideration of being permitted to enter and use the facilities, play area, programs, services and equipment at The Brick Lab LLC located at 5110 West Ridge Rd, Spencerport NY 14559 (“Premises”), the undersigned representative, on behalf of himself or herself and the participants identified below (the “Participants” and each a “Participant”) acknowledges and agrees to the following:

1.     I represent that I am the parent or legal guardian of the Participants named below or I have obtained permission from the parent or legal guardian of the Participants named below to execute this agreement on their behalf. I agree that the Participants named, and I shall comply with all stated and customary terms, rules, and instructions of The Brick Lab LLC as a condition of the entry and use of the facilities, play area, programs and services at the Premises.

2. I acknowledge and understand that there are known and unknown risks associated with the entry and use of the facilities, play area, programs and services at the Premises. I, for myself and the Participants named herein, knowingly and willingly assume any and all known and unknown risks associated with the entry and use of the facilities, play area, programs and services at the Premises which may or may not be expressly stated herein.

3. Use of the the brick lab facility, programs, services and equipment is at the undersigned and each participant’s sole risk. the premises are provided on an “as is” and “as available” basis. the undersigned represents that it has inspected The Brick Lab’s play area, facilities, programs and services and finds and accepts them as being safe and reasonably suited for itself and the participants. The Brick Lab expressly disclaims all warranties of any kind, whether express or implied. the undersigned on his or her behalf and on behalf of the participants assumes full responsibility for and risk of bodily injury, death or property damage while in, about or on the The Brick Labs’ premises or using The Brick Labs’ play area, facilities, services or equipment. the undersigned, on his or her behalf and on behalf of the participants, hereby waive and release any and all losses, liabilities, damages or claims against The Brick Lab, its members, managers, employees, and agents (the “released parties” and each a “released party”) on account of any injury to person or property or death of the undersigned and/or the participants, whether caused by negligence or gross negligence of the released parties while the undersigned and/or participants are about or on The Brick Lab’s premises or using the The Brick Lab’s play area or facilities. This release and waiver is intended to be as broad and inclusive as permitted by the laws of the state of new york and that if any portion thereof is held invalid, it is agreed that any remaining portions shall remain in full force and effect.

4. The undersigned agrees to indemnify and hold harmless each of the released parties from any and all loss, liability, or damage incurred as a result of his or her and/or a participant’s injury to person or property or death in, about or on the brick labs’ premises or use of the brick labs’ play area, facilities, services or equipment whether caused by the negligence or gross negligence of a released party.

Communicable Disease Release of Liability and Assumption of Risk Agreement


The BrickLab recognizes the current pandemic and has put in numerous preventative measures and enhanced cleaning protocols at its facility to reduce the likelihood of spreading COVID-19; however, The BrickLab cannot guarantee to you or your child(ren) will not become infected with COVID-19.
In consideration of being allowed to participate in any of The BrickLab’s programs, activities, and/or related events, I the undersigned, acknowledge, appreciate and agree that:
I acknowledge the contagious nature of COVID-19 and voluntarily agree to the participation in the programs, activities and/or related events and assume the risk that my child(ren) and I may be exposed to or infected by, directly or indirectly COVID-19 by attending the programs, activities and/or related events and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death.
I acknowledge my responsibility to not bring my child(ren) to the program, activities and/or related events if my child(ren) are exhibiting symptoms of COVID-19.
I, for myself and behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMIFY, AND HOLD HARMLESS The BrickLab, its owner, employees, other participants, lessors of the premises used to conduct the event (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any ILLNESS, INJURY, DISABILITY OR DEATH, I or my child(ren) may suffer, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

5. The undersigned has read and knowingly and voluntarily signs this assumption of risk, release and waiver of liability, indemnity agreement and acknowledges, understands and agrees to such terms.

 

First participants Name

First Name*

Middle Name

Last Name*

Phone*
First participants Date of Birth*
First participants Signature*
Second participants Name

First Name*

Middle Name

Last Name*
Second participants Date of Birth*
Third participants Name

First Name*

Middle Name

Last Name*
Third participants Date of Birth*
Fourth participants Name

First Name*

Middle Name

Last Name*
Fourth participants Date of Birth*
Fifth participants Name

First Name*

Middle Name

Last Name*
Fifth participants Date of Birth*
Sixth participants Name

First Name*

Middle Name

Last Name*
Sixth participants Date of Birth*
Seventh participants Name

First Name*

Middle Name

Last Name*
Seventh participants Date of Birth*
Eighth participants Name

First Name*

Middle Name

Last Name*
Eighth participants Date of Birth*
Ninth participants Name

First Name*

Middle Name

Last Name*
Ninth participants Date of Birth*
Tenth participants Name

First Name*

Middle Name

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

Email*

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

Middle Name

Last Name*

Phone*
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 - TRY IT FREE!