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Pikopye's Town Camp Participation Waiver - 2021

In Consideration to being allowed to enter and participate to one, any or all activities during Pikopye's Town ("The Company") Camps, the undersigned, on hisor her behalf, and on the behalf of the participant(s) identified during registeration, acknowledges, appreciates, and agrees to the following conditions:

I Agree
  I represent that I am a parent or legal guardian of the participant(s) named in this waiver and the registration form, or I have obtained permission from a parent/legal guardian of the participant(s) named abobe to execute this agreement on his or her behalf.

 

Policies & Procedures:

  • All reservations must be made no later than 24 hours before the camp date.  
  • All items must be brought from home must be labeled with the participant(s) name (blanket or water bottle).  Toys from home are not permitted and Pikopye's Town is not responsible for any lost, damaged or stolen items brought from home.
  • Any food allergies and medications must be communicated in writing during the booking process to ensure safety of the child. Pikopye's Town is not a nut-free facility.  
  • Cancellations and reschedule for another camp day is only allowed before June 7th.  There are strictly no refunds or credit for all cancellations after that date.

I Agree
I certify that I have read, understand and agree to the Policies & Procedures above.

 

Photo Release

I Agree
  I authorize Pikopye's Town the use of photos of the participant to be included in their Photo Gallery on their social media and website or any adverstising published by Pikopye's Town.

 

For Drop-offs:

  • It is my responsibility to arrange the participant(s) to be picked up from Pikopye's Time at Pick-up Time for this camp.  If the participant(s) is (are) not picked up on time, and attempts to contact me have failed, another Authorized Person will be contacted.  All Authorized Person must provide a photo identification and listed on the form I filled out.
  • In the event of an emergency, Pikopye's Town will attempt to contact me and if I cannot be reached, Pikopye's Town is authorizec to contact one of my provided Emergency Contacts.  In the event that no Emergeny Contact can be reached, Pikopye's Town is authorized to act for me, according to their best judgement in obtaining emergency medical treatment for any participant(s) name on the reverse.  
  • Pikopye's Town require all participant(s) is potty-trained.  In the event that the participant(s) need to use the bathroom to potty, I give Pikopye's Town permission to accompany them if necessary to ensure child's safety.  If I am not comfortable with this, I will let any of the staff know in writing upon drop-off.
  • I hereby testify that my child is toilet trained and that they can use the bathroom with minimal accompaniment of a staff member.

In case of Emergency

I Agree
 I provide my consent for The Company and its staff to seek emergency treatment for the participant in case of injury if necessary.  

I Agree
I agree to accept all financial responsibility for the costs related to the emergency treatment.

 

Release of Liability

I Agree
 I am aware that there are inherent risks associated with participation in Pikopye's Town Camps & Workshops, and I, on behalf of myself, and the participant(s) named on the form, knowingly and freely assume all such risk, both known and unknown, including those that may arise out of the negligence of other participants; and, I, or myself and the particpant(s) named, and our respective heirs, assigns, administrators, personal representatives, and next of kin, agree to indemnify and hold harmless, Pikopye's Town (Dalemi Group LLC), the management, their affiliates, officers, members, agents, employees, other participants, and sponsoring agencies from and agains any and all claims, injuries, liabilities, or damages arising out of or related to our particpation in any and all Pikopye's Town programs, camp activities, parties and use of the play areas.

By signing below, I agree to all of the above and that the participant below has my full consent to participate in the camp.  

First Participant Name

First Name*

Middle Name

Last Name*

Phone*
First Participant Date of Birth*
First Participant Signature*
Second Participant Name

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Third Participant Date of Birth*
Fourth Participant Name

First Name*

Middle Name

Last Name*
Fourth Participant Date of Birth*
Fifth Participant Name

First Name*

Middle Name

Last Name*
Fifth Participant Date of Birth*
Sixth Participant Name

First Name*

Middle Name

Last Name*
Sixth Participant Date of Birth*
Seventh Participant Name

First Name*

Middle Name

Last Name*
Seventh Participant Date of Birth*
Eighth Participant Name

First Name*

Middle Name

Last Name*
Eighth Participant Date of Birth*
Ninth Participant Name

First Name*

Middle Name

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

First Name*

Middle Name

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

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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