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Break ‘N Bash, LLC
2900 East Market Street
Greensboro, NC 27405
(336)454-9599

TERMS AND CONDITIONS WAIVER

In consideration of my being allowed to use the services, equipment, and facilities of Break ‘N Bash, LLC, I hereby and acknowledge and agree to the following terms and conditions: ASSUMPTION OF RISK:

I hereby acknowledge, accept and agree that the use of or participation in a break room, related activities, and the use of Break ‘N Bash’s services, equipment, and facilities is inherently dangerous. Participation in a break session and related activities may place unusual stresses on the body and is not recommended for persons suffering from asthma, epilepsy, cardio disorders, respiratory disorders, hypertension, skeletal, joint or ligament problems or conditions, and certain mental illnesses. Women who are pregnant or suspect they are pregnant and persons who have consumed alcohol or are otherwise intoxicated are not recommended to engage in break room sessions. I have been advised to consult with my medical practitioner if I have any concern about my medical condition or fitness to engage in a rage room session. I have received full information regarding Break ‘N Bash services, equipment, and facilities and have had the opportunity to ask any questions that I had regarding the same. I have full knowledge of the nature and extent of all the inherent risks associated with break rooms and the services, equipment, and facilities used in break rooms and related activities at Break ‘N Bash, which may include but are not limited to:

a. Any and all manner of injury, including without limitation the possibility of serious injury or death, resulting from any of the services, equipment, and facilities at Break ‘N Bash’s, including without limitation, slipping or tripping on debris and hitting the floor, equipment, weapons, people or debris, whether permanently or temporarily in place, failure to wear protective gear, flying debris or any other consequence whatsoever of utilizing Break ‘N Bash’s services, equipment, and facilities;

b. Injuries resulting from the actions or omissions of others, including but not limited to slips, trips and falls of other participants and flying debris;

c. Cuts and abrasions resulting from skin contact with damaged items, debris, or any other surface, person, or equipment;

d. Injuries resulting from shock, stress or other injuries;

e. The aggravation or worsening of any existing medical condition;

f. Failure or misuse of safety gear, weapons, or any other items or equipment;

g. Failure to follow Break ‘N Bash’s employee instructions or failure to ask for information or assistance;

h. Any injury that may occur while moving on or about the premises for any reason, including but not limited to slips, trips and falls, and any and all inherent risks of the use of or participation in a break room, and the services, equipment and facilities used in break rooms and related activities at Break ‘N Bash.

I further acknowledge that the above list is not inclusive of all possible inherent risks associated with the use of Break ‘N Bash’s services, equipment, and facilities, and I agree that such list in no way limits the extent or reach of this Assumption of Risk, Release and Indemnification.

Release
In consideration of my use of Break ‘N Bash’s services, equipment, and facilities, and/or participation in any program, competition, special event, group or party offered by or held at Break ‘N Bash, I hereby release and discharge Break ‘N Bash, as well as its members, managers, officers, directors, owners, employees, agents and contractors, from any and all liabilities, suits, claims, causes of action, demands, damages (including attorneys’ fees and expenses), losses or costs of any nature whatsoever incurred by me or that are in any way related to or arising out of the use or intended use of Break N Bash’s services, equipment, and facilities, whether supervised or not, including, without limitation, all claims for property damage, personal injuries or wrongful, whether or not there are any allegations or charges of negligent acts or omissions on the part of any other parties, including Break ‘N Bash (collectively, the “Claims”).

INDEMNIFICATION:
I hereby agree to indemnify Break ‘N Bash, as well as its members, managers, officers, directors, owners, employees, agents and contractors, from any and all liabilities, suits, claims, causes of action, demands, damages, losses or costs of any nature whatsoever arising out of, or in any way relating to, my use of or movement in or throughout Break ‘N Bash’s services, equipment, and facilities, whether or not there are any allegations or charges of negligent acts or omissions on the part of any other parties, including Break ‘N Bash.

I understand and agree that Break ‘N Bash and its personnel or staff reserves the right to deny access to its facilities to any individual, permanently or for a specified period of time, for any breach of Break N Bash’s policies, rules and regulations, for any conduct that is viewed as unsafe or inappropriate, or for any other reason whatsoever, whether disclosed or not. While using Break ‘N Bash’s services, equipment, and facilities, I consent to Break ‘N Bash capturing any form of media containing my image, be it photo or video, and agree that any such media may be used for any and all purposes that Break ‘N Bash deems appropriate in its sole and absolute discretion. Break ‘N Bash may add my email address to their mailing list for Break ‘N Bash updates and promotions.

This agreement shall be effective and binding upon my heirs, next of kin, executors, administrators and assigns, in the event of my death or incapacity. By signing this agreement, I waive the right to bring a court action to recover damages or obtain any other remedy for any injury to myself or death, or any damage to my property, however caused, arising out of my use of or movement in or throughout Break N Bash’s services, equipment, and facilities, now or any time in the future, whether or not there are any allegations or charges of negligent acts or omissions on the part of any other parties, including Break ‘N Bash. I agree to pay for any and all reasonable attorneys’ fees and expenses incurred by Break ‘N Bash as a result of any claims made by me or on my behalf in contravention of this agreement.

I am at least 18 years of age and legally competent to sign this agreement. This Assumption of Risk, Release and Indemnification shall be effective and binding upon me and upon my assigns, heirs, representatives, executors and administrators. If I am under the age of 18, this release must also be signed and filled out below by my parent or guardian.

My participation in this activity is purely voluntary, and I elect to participate in spite of the risks described herein. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, and I will agree to bear the costs of such injury or damage. I further certify that I have no medical or physical conditions which interfere with my ability to participate safely in the use of Break N Bash’s services, equipment, and facilities, or else I am willing to assume and bear the costs of all risks that may be created, directly or indirectly, by any such condition.

I agree that the validity and enforceability of this release of liability and assumption of risk will be governed by the laws of the State of North Carolina, without regard to its conflict of law rules, and venue for any proceedings regarding this agreement shall be in the state courts located in Guilford County, North Carolina. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

I have had sufficient opportunity to read this entire document, as well as the opportunity to ask questions about this document if I have any. By signing this agreement, I acknowledge that if anyone is hurt or property is damaged while I am on the premises, I may be found by a court of law to have waived my right to maintain a lawsuit against Break ‘N Bash, LLC as well as its members, managers, officers, directors, owners, employees, agents and contractors, on the basis of any claim from which I have released them herein.

Participant or Guardian Signature:


Date: October 24, 2021

Photo/Video Consent and Release Form

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Break ‘N Bash, LLC, its affiliates and agents, to use my image(s) and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the internet). This consent includes, but is not limited to:

  • Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice,
  • Permission to use my name, and
  • Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in this publication, in newspapers, magazines and other print media, on television, radio and electronic media (including the internet), in theatrical media and/or in mailings for educational awareness.

This consent is given in perpetuity, and does not require prior approval by me. I have read the release of informatio

First Participant's Name

First Name*

Middle 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*

Middle Name

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
PARENT’S ADDITIONAL ASSUMPTION OF RISK, RELEASE, AND INDEMNIFICATION TO BE READ AND SIGNED BY PARENT OR LEGALLY APPOINTED GUARDIAN OF MINOR In consideration of the above minor, being permitted by Break ‘N Bash to participate in its activities and to use its services, equipment, and facilities, I, hereby agree to release Break ‘N Bash from any and all Claims resulting from the aforementioned minor’s participation in or use of Break ‘N Bash’s services, equipment, and facilities and have described the risks and dangers of these activities to the minor, who chooses to participate in spite of the risks. I am familiar with and consent and agree to the terms and provisions set forth in this Assumption of Risk, Release and Indemnification, and I agree to all of its terms and conditions on behalf of myself and the aforementioned minor for whom I am signing. The below signed parent or legal guardian of the above named (if a minor child) hereby consents to and gives permission to Break ‘N Bash, LLC on behalf of such minor.
Parent or Guardian's Name

First Name*

Middle 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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