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PARTICIPANT WAIVER AND RELEASE OF LIABILITY

     In consideration of the opportunity to participate in the services of Break Room Therapy, LLC (BRT), whose registration process requires me to accept this Agreement, I hereby agree to the following Waiver and Release of Liability (Agreement):

1. WAIVER AND RELEASE OF LIABILITY: My participation in BRT activities is voluntary and subjects me to the possibility of physical injury (which could be minimal, serious, and/or result in death) and loss of or damage to my property (collectively, Risks). Accordingly, I agree to the following:

a. I hereby release and hold harmless BRT, its officers, directors, employees, agents, volunteers, and contractors (collectively, Releasees) from any claim, demand, loss, liability, damages, and attorney fees and costs whatsoever arising from, related to, or resulting from these Risks (Claims), including those caused by the negligent acts or omissions of any or all of the Releasees.

b. I recognize physical exertion may be involved in the BRT activities and attest and certify that I am physically fit to participate safely, and I have not been advised otherwise by a healthcare professional.

c. As between each of the Releasees and me, I will be solely responsible for any and all medical and related bills that I may incur because of any injury, as well as costs related to loss or damage to my property, that I or my child may sustain as a result of my or my child’s participation in the BRT activities.

d. This Agreement shall be binding on my estate, heirs, executors, administrators, successors, and assigns, as well as any other party asserting a Claim on my behalf or on behalf of my estate.

e. Should BRT, or anyone acting on its behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold BRT harmless for all such fees and costs.

2. GENERAL PROVISIONS:

a. I hereby expressly agree that (1) this Agreement shall be governed and construed according to the laws of the State of Michigan, without regard to its conflict of laws provisions and (2) any action or proceeding concerning any Claim or the meaning or effect of any provision of the Agreement shall be conducted only in the federal or state courts location in Kent County, Michigan, and that for such purposes, I expressly submit to the jurisdiction of such courts.

b. This Agreement contains the entire understanding between and among the parties concerning these matters. No waiver, modification, or amendment of any of the terms of this Agreement shall be effective unless made in writing and signed by the party to be charged.

c. I hereby expressly agree that if any portion of this Agreement is held invalid, the balance of the Agreement shall nonetheless continue in full legal force and effect.

     I warrant that I have read and understand this Agreement involves my waiver and release of significant rights and my assumption of significant indemnification responsibilities in participating in BRT activities.

Date: February 20, 2024

House Rules!

I agree that participation at BRT means I will follow all house rules.

*When a session is booked it is booked for a set time. Participants need to arrive no less then 15 minutes before their scheduled session for safety instructions and check in process. Arriving late will impact your session. For example, a 2pm session has a 1:45 arrival time and arriving late can impact the amount of time you have for your session. 

*All participants must be 13 or older and everyone 13-17 must have an adult present for the whole session.

*Thick soled tennis shoes or heavy work boots (with no visible heels of any size) are mandatory. No exceptions!

*Absolutely NO sandals, flip flops, crocs, ladies' flats, hey-dude shoes, wedge shoes & heels (of any size including those on boots!) or loafers are allowed. If a staff member says your shoes do not qualify as acceptable shoes- their decision is final. At that point you can rent shoes for $10 if available or not participate. The staff is following rules set forth by the insurance.

*Any participants appearing to be under the influence of drugs and/or alcohol will also not be allowed to participant.

*At no point are more than 2 participants allowed to be in the room at a time unless the session is not active, and the door is open- for example while taking photos. The rooms have windows on them so when not actively in the room you are still with your group. 

*Only one wall of the room is allowed to be hit, which will be explained during safety instructions. Any action of purposely hitting the other walls will result in the session immediately ending and participation will be over.  

READ BELOW- I agree with the rules noted above and all rules that will be verbally provided to me during the safety instructions. **By clicking this I also agree I have been provided the rules above, agree to them and have read them. *
I agree to the rules noted below
First Participants Name

First Name*

Last Name*

Phone*
First Participants Age Acknowledgment*
First Participants Date of Birth*
I certify that I am 18 years of age or older
First Participants Preferred Name

Preferred Name:
First Participants Signature*
Second Participants Name

First Name*

Last Name*
Second Participants Date of Birth*
Second Participants Preferred Name

Preferred Name:
Third Participants Name

First Name*

Last Name*
Third Participants Date of Birth*
Third Participants Preferred Name

Preferred Name:
Fourth Participants Name

First Name*

Last Name*
Fourth Participants Date of Birth*
Fourth Participants Preferred Name

Preferred Name:
Fifth Participants Name

First Name*

Last Name*
Fifth Participants Date of Birth*
Fifth Participants Preferred Name

Preferred Name:
Sixth Participants Name

First Name*

Last Name*
Sixth Participants Date of Birth*
Sixth Participants Preferred Name

Preferred Name:
Seventh Participants Name

First Name*

Last Name*
Seventh Participants Date of Birth*
Seventh Participants Preferred Name

Preferred Name:
Eighth Participants Name

First Name*

Last Name*
Eighth Participants Date of Birth*
Eighth Participants Preferred Name

Preferred Name:
Ninth Participants Name

First Name*

Last Name*
Ninth Participants Date of Birth*
Ninth Participants Preferred Name

Preferred Name:
Tenth Participants Name

First Name*

Last Name*
Tenth Participants Date of Birth*
Tenth Participants Preferred Name

Preferred Name:
Participants 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*
PARENTS OR GUARDIANS ADDITIONAL INDEMNIFICATION (MUST BE COMPLETED FOR PARTICIPANTS UNDER THE AGE OF 18): In consideration of the following minor(s) (clearly print Minor's or Minors' name(s)) being permitted by BRT to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless BRT from any and all claims which are brought by, or on behalf of Minor(s), and which are in any way connected with such use or participation by Minor(s). All minors must have an adult present on site and within viewing of the minors session during the whole time on the premises.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Preferred Name

Preferred Name:
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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