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Broome Hippodrome
161 North Jensen Road, Vestal, NY 13850

Please read carefully. By signing this form you are waiving all rights to compensation in case of injury Liability Release and The Assumption of Risk

For participants Broome Hippdrome

In and for consideration of The Hippodrome (the “Gym”,) USA Parkour, LLC allowing the participation of myself or child.

In training, recreational, and any and all other activities at facilities or events, indoor or outdoor, operated by the Gym, I, on myself or my child’s behalf and on behalf of his/her and my heirs, devisees, agents and/or representatives, and each of them hereby release and indemnify the Gym and its members, managers, employees, volunteers, trainers, trustees, beneficiaries, successors, assigns, agents and/or representatives and each of them of and from all liability for personal injuries my child may suffer arising out of, or in any way related to, my child’s use of the facilities operated by the Gym.

I understand that my or my child’s participation in obstacle courses, weight lifting, fitness classes, personal training, and any and all other activities at the facility operated by the Gym is at his/her own risk. The risks include but are not limited to: falling off of obstacles, loose or damaged training equipment or obstacles, falling to the ground, falling on others, or being fallen on by others; training out of control or beyond one’s personal limits. I agree to pay attention to the state of equipment and obstacles in the gym and to advise staff if I do any damage or notice any damage. Furthermore, Broome Hippodrome trainers may be unaware of a participant’s fitness or abilities.

I agree to participate in all activities at my own risk and to be aware of my own personal limitations. I also understand that no assurance guaranteeing my or my child’s safety is being made by the Gym or its members, managers, employees, volunteers, trainers, agents and/or representatives.

I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors, organizers, and assigns.

I agree to observe and obey all rules and warnings, and further agree to follow any oral instructions or directions given by Broome Hippodrome trainers.

I agree to pay for all damages to the facility of Broome Hippodrome caused by me or my families negligent, reckless, or willful actions.

I understand that my child’s participation in obstacle courses, weight lifting, fitness classes, personal training, and any and all other activities at the facility operated by the Gym could result in physical or emotional injury, paralysis, death, or damage to my child, to property, or third parties.

I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.

By signing this waiver for a minor, I affirm that I am the parent/legal guardian of the child listed above.

I have read, understand, and agree to follow these rules. By signing for a minor, you agree that they have read, understand, and will follow the rules of the gym.

Today's Date: January 25, 2022

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Participant'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 to receive information, news, and discounts by e-mail.
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*

Relationship*

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.


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