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Little Beakers - Utah Participation Waiver for Group Events


IMPORTANT: THIS IS A LEGAL DOCUMENT

PLEASE READ AND UNDERSTAND THIS DOCUMENT BEFORE SIGNING

PARTICIPANT INFORMED CONSENT TO TREATMENT, WAIVER, AND RELEASE FOR LITTLE BEAKERS PROGRAMS AND ACTIVITIES

This Agreement must be completed by an adult authorized by the Participants' parent/s or guardian/s to participate in activities at Little Beakers - Sandy or Little Beakers - Orem in order to participate in the activities associated with the Little Beakers program. 

CONSENT TO TREATMENT, WAIVER AND RELEASE

I acknowledge that Participants are minors under 18 years of age and under my care. I further acknowledge that I have received express permission from each Participant's respective parent/s or legal guardian/s for them to attend and participate in the Group Event scheduled at Little Beakers on the specified date. 

I am familiar with the curriculum and the activities which will take place in the above named program (the "Program") offered through Learning Science Labs 1, LLC, doing business as Little Beakers - Sandy and Little Beakers - Orem (herein as Company). I understand that participation in the Program can include foreseeable and unforeseeable risks and other hazardous activities inherent in the program, including but not limited to skin and eye reactions and irritation, which may expose me and the child(ren) in my care to illness, injury or death.

I state that to the best of my knowledge, unless otherwise communicated, the Participant/s is/are free from any known respiratory or other health concern (ie. allergies) that could prevent participants from safely participating in the Program or any of its activities. In the event that a Participant has a respiratory or other health concern, Company will be notified in advance and appropriate efforts will be taken to limit or remove potential exposure.

Company will communicate rules of conduct, guidelines and Company policies relating to this Program upon our group's arrival. I understand and acknowledge it is my responsibility to ensure that I and all minors' under my care utilize all safety equipment and follow the safety guidelines and policies of the Company. The acknowledged, authorized caregiver assumes risk for a child left unattended.

In the event of an injury, accident or emergency, I acknowledge that I have been given express consent and authorization from each Participant’s parent/s or legal guardian/s for their child to be transported to a hospital or emergency room for medical treatment and I am responsible for obtaining any necessary medical aid, anesthesia and/or operation, if in the opinion of the attending physician, such treatment is necessary for the Participant. The full responsibility for such decisions lies with the acknowledged, authorized guardian not Company and Company will be held harmless in the execution of such. I certify that Company will not be responsible for any costs or medical expenses which may be incurred as a result of any injury related to the Program or sustained while participating at Little Beakers.

I acknowledge that individual and group publicity photos and videos may be taken during the group event and Participant images and/or likenesses may be used in future Company publicity or advertising without additional notice.

In consideration of my, and all minors under my care, participation in the Program and activities of Company, I hereby for myself and my child(ren) and our respective heirs and successors, release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes Company, its members, officers, agents, volunteers or employees from any and all liabilities, claims, demands, injuries, costs of medical care, or damages, including court costs and attorney fees and expenses, that may be sustained while participating in the Program and/or its activities or while on the premises of Company including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of Company. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct. 

If any portion of this Agreement is held to be invalid by a court of law, then it is agreed and intended that all the remainder shall, notwithstanding, continue in full force and effect. 

I have read and understand everything contained herein and agree to be so bound. I acknowledge that by this Agreement, I have freely and voluntarily given up certain legal rights and possible claims that I might otherwise assert or maintain against Company, including specifically, but not limited to, rights arising from or claims for the negligent acts or omissions of Company. I assume responsibility and legal liability for the claims or other legal demands, including defense costs, which may be asserted by third parties against me or Participant as a result of Participant's participation in the Program. 

Participant has been advised to maintain health & accident insurance to cover the costs of treatment in the event of any injury or illness. 

Revised 4/21/25



First Customer's Name
First Name*
Last Name*
First Customer's Age Acknowledgment*
First Customer's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Customer's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

First Customer's Signature*
Second Customer's Name
First Name*
Last Name*
Customer's Date of Birth*
Date of Birth
Second Customer's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

Third Customer's Name
First Name*
Last Name*
Customer's Date of Birth*
Date of Birth
Third Customer's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

Fourth Customer's Name
First Name*
Last Name*
Customer's Date of Birth*
Date of Birth
Fourth Customer's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

Fifth Customer's Name
First Name*
Last Name*
Customer's Date of Birth*
Date of Birth
Fifth Customer's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

Sixth Customer's Name
First Name*
Last Name*
Customer's Date of Birth*
Date of Birth
Sixth Customer's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

Seventh Customer's Name
First Name*
Last Name*
Customer's Date of Birth*
Date of Birth
Seventh Customer's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

Eighth Customer's Name
First Name*
Last Name*
Customer's Date of Birth*
Date of Birth
Eighth Customer's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

Ninth Customer's Name
First Name*
Last Name*
Customer's Date of Birth*
Date of Birth
Ninth Customer's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

Tenth Customer's Name
First Name*
Last Name*
Customer's Date of Birth*
Date of Birth
Tenth Customer's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

Parent or Guardian's Email Address
Email*
Check the box below to receive periodic emails about Little Beakers' events, offers and news.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Please let us know how you heard about Little Beakers and where you are coming from:
Zip Code *
How did you hear about us? (Please check all that apply) *
Friend / Family
Birthday Party / Field Trip
Kids Out And About
Internet Search
Social Media
City Journal
Your child's school
Other
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*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Name of your school or organization: *
Main Contact Number for Organization *
The date your group is schedule to visit the lab. *
Primary contact on day of event *

In addition to the completion of this form by an authorized individual of your organization or school, please ensure the following steps are completed prior to your arrival on the day of your event: 

1. All teachers, parents, chaperones, or any other adults with your school or organization who will be entering the lab have completed the Registration and Participation Waiver for Adults which can be found on the home page of the Little Beakers website www.littlebeakers.com. Hardcopies will not be accepted.

2. Bring a roster that includes all children participating (Little Beakers staff will make a copy) on the day of the event.

Parent or Guardian's Signature*
Electronic Signature Consent*
 I understand and acknowledge that by electronically signing this Agreement, I am agreeing to be bound by its terms and conditions. MY ELECTRONIC SIGNATURE INDICATES THAT I HAVE READ THE ENTIRE AGREEMENT, UNDERSTAND THAT IT AFFECTS MY LEGAL RIGHTS, AND UNDERSTAND THAT IT WAIVES MY RIGHT TO SUE COMPANY. 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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