Segway Waiver

First Participant's Name

First Name*

Last Name*

Phone*

First Participant's Date of Birth*

First Participant's Signature*

Type Signature

Draw Signature

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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*

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Minors: I hereby represent that I am the parent or legal guardian of ("the Minor(s)") who is (are) under the age of 18, but weigh(s) no less than 100 lbs. in consideration of Action Zipline Inc. the Minor(s) to use voluntarily the SegwayTM as described herein, and I release its directors, officers, employees, and agents from all claims, demands, suits, causes of action, or judgments for personal injuries, known or unknown, property damages, or claims for wrongful death, caused by their acts, omissions or negligence committed on their behalf and in their name which the Minor(s) or I may have in the future or which our heirs, executors, administrators, or assigns may have, or claim to have arising out of or in any way connected with the SegwayTM. I further agree to indemnify and hold harmless, its directors, officers, employees, and agents from all claims, demands, suits, causes of action, or judgments which the Minor(s) or I may have in the future or which our heirs, executors, administrators, or assigns may have, or claim to have, arising out of or in any way connected with the SegwayTM. I also agree to be responsible for any property damage or personal injuries that I or the Minor(s) may cause by intentional or negligent acts while using the Segway T"'.

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*

Relationship*

Phone*

Parent or Guardian's Date of Birth*

Parent or Guardian's Signature*

Type Signature

Draw Signature

Click to Sign

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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Agree To This Document