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I, Client of Recess Playspace, LLC, DBA Recess PlayWorks (hereinafter referred to as Company) and the Parent to the Child(ren) listed above, hereby consent to the administration of emergency medication to the above-named Child(ren) in instances of ingestion of a severe allergen, anaphylaxis and/or other, allergy- related emergency according to the dosing instructions provided to Company staff.

EMERGENCY CONSENT

When a child is ill or needs medical attention, The Company will make an effort to get in touch with the off-site parent/guardian that signed the child into the Playspace. If that parent/ guardian cannot be reached, We will make an effort to contact the second parent/guardian and/or the listed emergency contact. If they cannot be reached and we need to get immediate help for the child, the child will be taken to the nearest emergency service, via ambulance.

Please sign below so that we can take appropriate action on behalf of your child.

I HEREBY GIVE MY/OUR CONSENT FOR MY/OUR CHILD(REN) WHEN ILL AND/OR INJURED, TO BE TAKEN TO THE NEAREST EMERGENCY CENTER IF I/WE CANNOT BE CONTACTED. I CONSENT TO AN AMBULANCE BEING CALLED TO TRANSPORT THE CHILD, IF NECESSARY. I FURTHER AGREE TO PAY ALL COSTS INCURRED FOR TRANSPORT AND ALL MEDICAL COSTS RELATED TO INJURY AND/ OR ILLNESS.

LIABILITY WAIVER

Please carefully read these Terms and Conditions of Use (“Terms and Conditions”) before using www.recessplayworks.com (the Website), the Co-Work Services or the Childcare Services (collectively, “Services” outlined below) of Recess Playspace, LLC (the “Company”). This Agreement for Terms and Conditions of Use (“Agreement”) is made and entered into and the effective date of signing by and between the Company, Recess Playspace, LLC, a Connecticut Limited Liability Company located on 66 Danbury Road, Ridgefield, CT and the party’s whose name is contained in the registration form (“Client”) and is signed on behalf of Client and Client’s child or children (hereinafter referred to as “the Child”) who participate in the Company’s activities.

Release and Waiver of Liability

By signing this Agreement, the Client, on behalf of him or herself, the Child and the Client’s spouse, heirs, next of kin, assigns, executors, administrators, Clients, agents successors, employees, representatives, invitees, licensees or any other who may claim on Client or the Child’s behalf (collectively referred to hereinafter as “Client”) herby voluntarily and irrevocably promises not to sue, and waives, releases and discharges the Company, its Clients, owners, employees, trustees, contractors, volunteers, representatives, agents, assigns licensees, invitees and successors, and anyone else acting for on its behalf the owner/lessor of the Premises, and/or anyone using the Premises (collectively referred to hereinafter as

“Company”) from any and all liability present, past and in the future, losses claims, demands, actions or rights of action, costs or expenses (including without limitation, reasonable attorneys’ fees and costs), or damages of any kind related to, relating to, arising out of, or incidental to Client or the Client’s Child with Company; the Client Services; Client or Child’s use of the Premises or the business conducted by Client therein; any other programs offered or sponsored by Company; any actor or omission by Client or Child; or any default by Client under this Agreement. This Release and Waiver applies to all claims, foreseen and unforeseen, including negligence and breach of statutory or other duty of care. CLIENT UNDERSTANDS AND AGREES THAT THIS RELEASE AND WAIVER IS INTENDED TO BE AS BROAD AND INCLUSIVE AS PERMITTED BY LAW, THIS RELEASE AND WAIVER INCLUDES WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF EQUIPMENT THAT MAY MALFUNCTION OR BREAK; ANY SLIP OR FALL WITHIN PREMISES; AND ANY OTHER AILMENTS, INJURIES, OR DEATH. Client agrees that if Client or Child, or anyone on Client or Child’s behalf, assert a claim contrary to what Client has agreed to therein, the claiming part shall be liable for the expenses (including legal fees) incurred by Company in defending such claim. CLIENT UNDERSTANDS THAT HE OR SHE HAS FORFEITED HIS OR HER AND THEIR CHILD’S RIGHT TO SUE COMPANY, ANT THAT THIS IS A RELEASE OF LIABILITY THAT IS VALID FOREVER.

Indemnification

Client further voluntarily and irrevocably agrees to indemnify, defend and hold harmless, at his or her sole expense, Company of and from any and all liability present, past and in the future, losses, claims, demands, actions or rights of action, costs or expenses (including without limitation, reasonable attorneys’ fees and costs), or damages related to, relating to, arising out of, or incidental to Client and Client’s Child with Company; the Client Services; Client or Child’s use of the Premises or the business conducted by Client therein; and any other programs offered or sponsored by Company; any act or omission by Client or Child; or any default by Client under this Agreement, including but not limited to damages in respect of death, injury, loss or damage to Client or Child, such as personal, bodily , or mental/ emotional injury, economic loss or any damage to Client or Child, or by Client or Child how so ever caused. Client acknowledges that Company shall not be responsible for damages, direct or consequential, resulting from any delay, unavailability, failure or interruption of any of the Client Services described under this Agreement or agreed to by Company.

Acknowledgment and Assumption of Risks

Client acknowledges and agrees that the use of Company’s Co-work and Playspace Services pose inherent risks that may result in injury , even serious or disabling, or death to Client and Child, and that this risk is always present and cannot be entirely eliminated. Client assumes full responsibility for his or her conduct and the conduct of his or her Child. CLIENT HEREBY VOLUNTARILY AND EXPRESSLY ASSUME ALL AND ANY RISKS INHERENT IN CLIENT AND CHILD’S PARTICIPATION IN THE CO-WORK AND THE PLAYSPACE AND ON THE COMPANY PREMISES INCLUDING THE RISK OF INJURY, ACCIDENT, DEATH, LOSS, COST OR DAMAGE TO CLIENT OR HIS OR HER CHILD’S PERSON OR PROPERTY. THIS RELEASE EXPRESSLY INCLUDES THE ASSUMPTION OF RISK AND RELEASE OF ANY CLAIMS FOR INJURIES OR DAMAGES ALLEGED TO RESULT

FROM OR ARISE OUT OF ANY NEGLIGENCE BY THE COMPANY, INCLUDING WITHOUT LIMITATION, ALL PREMISES OR PRODUCT’S LIABILITY CLAIMS.

CLIENT RECOGNIZES THAT BY SIGNING THIS AGREEMENT, CLIENT IS WAIVING CERTAIN LEGAL RIGHTS INCLUDING ANY RIGHT OF THE CLIENT OR THE CLIENT’S SPOUSE, HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATOR AND ASSIGNS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST COMPANY. CLIENT INTENDS FOR CLIENT’S SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF LIABILITY OF COMPANY TO THE GREATEST EXTENT PERMITTED BY LAW.

Today's Date: April 9, 2020

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

First Participant's Signature*
Second Participant's Name

First Name*

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

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

Third Participant's Name

First Name*

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

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

Fourth Participant's Name

First Name*

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

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

Fifth Participant's Name

First Name*

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

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

Sixth Participant's Name

First Name*

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

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

Seventh Participant's Name

First Name*

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

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

Eighth Participant's Name

First Name*

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

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

Ninth Participant's Name

First Name*

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

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

Tenth Participant's Name

First Name*

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

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

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*

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

Medical Information


Doctor

Phone

Address

CLIENTS AGREE TO KEEP THEIR CHILDRENS' IMMUNIZATIONS CURRENT. 


ALLERGIES Please list any known allergies of Client or Child and indicate who has the allergy.

If either Child or Client has a severe allergy, Client is responsible for ensuring that an Eippen or similar instrument is available to the Company staff at all times, that Company staff are aware of such allergy. Further, to permit Company's administration of such instruments to the Child in case of am emergency 

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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