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As legal guardian of the minor(s) listed below, (hereafter referred to as “Releasor”), I recognize what potentially severe injuries, including permanent paralysis or death can occur in all attractions at Little Harts Play Cafe, including, but not limited to, slide, climbing structure, bikes, and all other activities. Being fully aware of these dangers, I voluntarily consent to the aforementioned person(s) participating in any and all Little Harts Play Cafe (hereinafter referred to as “Little Harts Play Cafe”) attractions and activities and I ACCEPT ALL RISKS associated with that participation.

In consideration of being permitted to participate in activities at Little Harts Play Cafe, on behalf of Releasor and our respective heirs, legal representatives and assigns, I hereby release, waive and discharge Little Harts Play Cafe, its officers, directors, employees and agents from all liability to the releasor, their respective heirs, administrators, executors, and successors, for any and all loss or damage, in any claim or damages resulting therefrom, on account of injury to child, person or property, even injury resulting in death of the Releasor, whether caused by the negligence of Little Harts Play Café or otherwise while the Releasor is participating in any activity at the Little Harts Play Cafe. 

Releasor agrees to indemnify Little Harts Play Cafe, its officers, directors, shareholders, employees and agents from any loss, liability, damage or cost they may incur due to the presence of releasor in or upon the Little Harts Play Cafe, whether caused by the negligence of Little Harts Play Café or otherwise.

Releasor expressly agrees that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Indiana, and that if any portion thereof is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect. 

I further release all employees of Little Harts Play Café from any claim whatsoever on account of first aid, treatment or service rendered during Releasor’s participation in activities at the Little Harts Play Café. In the event of an emergency, I would like my above mentioned Releasor to be taken to a hospital for medical treatment and I hold Little Harts Play Café and its representatives harmless in their execution of this action. 

By your attendance at Little Harts Play Café, you are granting your permission for you and Releasor to be filmed, videotaped, audiotaped or photographed by any means and are granting full use of your likeness, voice and words without compensation.

This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital. 

Releasor further states that he/she has carefully read the foregoing release and knows the contents thereof and signs this release as his/her own free act.

In witness whereof, releasor has executed this release on the day of December 22, 2024.

First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Medical conditions or allergies we should be aware of?
First Participant's Signature*
Second Participant's Name

First Name*

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

Medical conditions or allergies we should be aware of?
Third Participant's Name

First Name*

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

Medical conditions or allergies we should be aware of?
Fourth Participant's Name

First Name*

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

Medical conditions or allergies we should be aware of?
Fifth Participant's Name

First Name*

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

Medical conditions or allergies we should be aware of?
Sixth Participant's Name

First Name*

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

Medical conditions or allergies we should be aware of?
Seventh Participant's Name

First Name*

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

Medical conditions or allergies we should be aware of?
Eighth Participant's Name

First Name*

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

Medical conditions or allergies we should be aware of?
Ninth Participant's Name

First Name*

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

Medical conditions or allergies we should be aware of?
Tenth Participant's Name

First Name*

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

Medical conditions or allergies we should be aware of?
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Email Address

Email*

Confirm Email*
Would it be ok to contact you about future promotions?
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.


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*

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

Medical conditions or allergies we should be aware of?
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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