Loading...

FLAGLER CLUB

COVID-19

ACKNOWLEDGMENT, RELEASE AND INFORMED CONSENT
FOR CHILD UNDER THE AGE OF 18

The Breakers Palm Beach, Inc. (“The Breakers”) provides Flagler Club level services for its guests at their request, which include enhanced concierge and food and beverage services served in exclusive Flagler Club level private lounge and rooftop terrace spaces, as well as complimentary chauffeured transportation services. The Breakers endeavors to follow both governmental mandates and recommendations as well as guidance from the Centers for Disease Control (CDC) as it relates to COVID-19 for social gatherings.  While precautions are taken and ample space for social distancing is provided, The Breakers is unable to control guest conduct and behavior, and so recommended social distancing may not always be maintained. As a result, per Palm Beach County Order 2020-12, all guests must wear a facial covering when entering, exiting and moving throughout indoor, public common areas, including indoor Flagler Club spaces and while using chauffeured transportation services. Further, because The Breakers does not control the behavior of Flagler Club guests, The Breakers does not assume any responsibilitywith respect to potential exposure to COVID-19. In order to provide these services, we require that all guests provide the following acknowledgment and release.  

I grant the child(ren) listed below permission to take part in the Flagler Club level services provided by The Breakers. This consent includes any and all activities and services undertaken as a guest at Flagler Club.

In and for consideration of my child(ren)'s participation, I, as a parent/guardian of the below named child(ren), on behalf of my child(ren), hereby agree to the following:

Acknowledgment

I acknowledge that there is a risk of COVID-19 exposure in any public place where people are present.  COVID-19 is highly contagious and can lead to illness and death. The Breakers has taken enhanced health and safety measures recommended by the CDC, however, the risk of contracting COVID-19 cannot be completely eliminated, and the services I am requesting necessarily involve use of public space and interaction with other people.  Therefore, I voluntarily assume all risks related to exposure to COVID-19.

 

I Agree

Release

In and for consideration of The Breakers providing the Flagler Club services, I assume the inherent risk of exposure to COVID-19 by my child(ren) being a guest in the Flagler Club leveland waive and release, in advance, The Breakers, The Breakers Palm Beach, Inc., Flagler System Inc., and their parent companies, subsidiaries, affiliates, officers, directors, shareholders, employees, agents, successors and assigns (collectively The Breakers Parties) from and against any and all costs, claims, demands, losses, expenses, damages or causes of action (including but not limited to attorney’s fees at all judicial levels), that my child(ren) have now or may have in the future (or that my child(ren)’s executors, administrators, heirs, next of kin, successors or assigns may have now or may have in the future) for any claims, liabilities, damages, actions or costs directly or indirectly arising from or in connection with potential or actual exposure to COVID-19 (including but not limited to liability for medical malpractice arising out of or relating to any treatment or care from employees, nurses, doctors, hospitals or other medical units, for any injuries sustained by my child(ren)), arising out of or resulting in any manner from being a guest in the Flagler Club at The Breakers, including transportation if applicable.  I understand that this waiver and release includes any claims arising out of the action(s) or inaction(s) of the employees or agents of The Breakers Parties.

I Agree

NOTICE TO THE MINOR CHILD'S NATURAL GUARDIAN

READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD(REN) ENGAGE IN A POTENTIALLY DANGEROUS EVENT. YOU ARE AGREEING THAT, EVEN IF THE BREAKERS PARTIES USE REASONABLE CARE IN PROVIDING THIS EVENT, THERE IS A CHANCE YOUR CHILD(REN) MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS EVENT BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD(REN)'S RIGHT AND YOUR RIGHT TO RECOVER FROM THE BREAKERS PARTIES IN A LAWSUIT FOR ANY ILLNESS INCLUDING COVID-19, PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD(REN) OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE EVENT. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND THE BREAKERS PARTIES HAVE THE RIGHT TO REFUSE TO LET YOUR CHILD(REN) PARTICIPATE IF YOU DO NOT SIGN THIS FORM.

I fully understand, acknowledge and agree that The Breakers is relying upon my electronic signature and this document, which is intended to induce The Breakers to allow my child(ren) to participate in Flagler Club level services. I further acknowledge that The Breakers has accepted this document as partial consideration for the participation of my child(ren) in the Flagler Club level services.

Informed Consent

I acknowledge that I have read this document carefully and fully understand its meaning, and I am voluntarily executing same as the parent/guardian for each minor guest.  Further, I fully understand, acknowledge, and agree that The Breakers Parties are relying upon my electronic signature and this document, which is intended to induce The Breakers Parties to provide Flagler Club services during the COVID-19 pandemic. I further acknowledge that The Breakers Parties have accepted this document as partial consideration for coordination of the Flagler Club services on my behalf.

Today's Date: December 2, 2020

First Guest's Name

First Name*

Last Name*
First Guest's Date of Birth*
I certify that I am 18 years of age or older
First Guest's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
First Guest's Signature*
Second Guest's Name

First Name*

Last Name*
Second Guest's Date of Birth*
Second Guest's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
Third Guest's Name

First Name*

Last Name*
Third Guest's Date of Birth*
Third Guest's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
Fourth Guest's Name

First Name*

Last Name*
Fourth Guest's Date of Birth*
Fourth Guest's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
Fifth Guest's Name

First Name*

Last Name*
Fifth Guest's Date of Birth*
Fifth Guest's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
Sixth Guest's Name

First Name*

Last Name*
Sixth Guest's Date of Birth*
Sixth Guest's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
Seventh Guest's Name

First Name*

Last Name*
Seventh Guest's Date of Birth*
Seventh Guest's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
Eighth Guest's Name

First Name*

Last Name*
Eighth Guest's Date of Birth*
Eighth Guest's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
Ninth Guest's Name

First Name*

Last Name*
Ninth Guest's Date of Birth*
Ninth Guest's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
Tenth Guest's Name

First Name*

Last Name*
Tenth Guest's Date of Birth*
Tenth Guest's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
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*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Flagler Club Reservation

Guardian's Full Name: *

Date of arrival: (ex: 10/29/20) *
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!