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The Relief Room

Liability Waiver for The Relief Room LLC

In consideration of the services rendered at The Relief Room LLC, their owners, managers, employees, and all other persons or entities acting in any capacity on their behalf, I hereby agree to release, indemnify, and discharge The Relief Room LLC, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I acknowledge that my participation in The Relief Room LLC activities entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to my personal property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essence of the activity. The risks include but are not limited to: slipping; falling; flying debris; collision with fixed objects; strains, sprains; broken bones; musculoskeletal injuries; emotional injury; cuts; abrasions; bruises; cardiac arrest; organ damage; hearing loss; negligence of participants adhering to safety instruction; equipment failure; and the physical exertion associated with this activity.

Furthermore, The Relief Room LLC employees have difficult jobs to perform. They seek safety for participants involved with each session, but they are not infallible. They might be unaware of a participant's fitness or abilities. They might misjudge the condition of the facilities or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction.

2. I agree and promise to accept and assume all of the risks associated in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the anticipated and unanticipated risks.

3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless The Relief Room LLC from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity. This may include but not be limited to my use of the equipment or facilities, including any such claims which allege negligent acts or omissions of The Relief Room LLC.

4. Should The Relief Room LLC or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.

6. In the event that I file a lawsuit against The Relief Room LLC, I agree to do so solely in the state of New York, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining document shall remain in full force and effect.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against The Relief Room LLC on the basis of any claim from which I have released them herein.

Video/Photo Consent:

I understand that all material obtained will be used by The Relief Room for educational and research related purposes, including external distribution via satellite broadcast, cable TV, radio broadcast, webcast or on-demand streaming in digital format on the Internet. The Relief Room may also share this material with others, as appropriate. I understand that I will receive no compensation for my consent to participate in this purpose. I understand that the recordings or photographs will become the property of The Relief Room and I understand that use of the materials may include, but not necessarily be limited to, the following:

  • Internal use at The Relief Room and other institutions in streaming digital format (live or on demand) on the Internet or other digital media.
  • Distribution (may include videotape reproduction, satellite broadcast, cable TV, webcast, on-demand, or social media content.)

I have read this form and have the opportunity to ask questions about the use of videos or photos. I hereby consent to the videotaping/photographing/audio recording of myself, in the material submitted by The Relief Room, and its affiliates.

Today's Date: December 10, 2019

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
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*
Parent or Guardian's Email Address

Email*

Confirm Email*
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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*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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