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1329 Alum Spring Rd., Suite 101

Fredericksburg, VA 22401

540-569-9820

info@milestonesgym.com

www.milestonesgym.com

I desire to use and grant the permission necessary to allow the minor(s) of whom I am the legal guardian or parent of to participate in all activities at the facilities at Milestones Play Gym & Pediatric Therapy located at 1329 Alum Spring Rd, Suite 101, Fredericksburg, VA 22401. This assumption of Risk, Waiver, and Release of Liability covers all activities at the gym. 1. Risk Factors- I understand and acknowledge that the use of the facilities at Milestones Play Gym & Pediatric Therapy involves risks including, but not limited to the following: bodily injury including cuts, scrapes, bruises, rug burns, sprains, fractures, but not limited to permanent disability, paralysis, and death. These risks may result from a variety of circumstances and cannot be eliminated without jeopardizing the qualities of the activities. 2. Assumption of Risk- I am choosing to use the facilities at Milestones Play Gym & Pediatric Therapy at my own risk. I understand and acknowledge that the activities which I am (or/and any minor children for which I am the parent, legal guardian, or otherwise responsible for) am about to voluntarily engage in as a participant and or volunteer bears certain known risks and unanticipated risk could result in injury, death, illness or disease, physical or mental, or damage to myself, or to spectators or third parties. I assume full responsibility for all risks that may arise from use of the facilities or participating in activities at Milestones Play Gym & Pediatric Therapy. 3. Acknowledgement of Policies and Procedures- I acknowledge that I have read, know, and agree to all the policies and procedures relating to the use of the facilities at Milestones Play Gym & Pediatric Therapy. I agree to comply with all rules, regulations, and policies and procedures relating to the use of the facilities at Milestones Play Gym & Pediatric Therapy. I understand Milestones Play Gym & Pediatric Therapy reserves the right to revoke or terminate my use of the facilities at Milestones Play Gym & Pediatric Therapy for any violation of rules, regulations, or policies. 4. Release, Indemnify, Defend- I hereby release, waive, discharge, and hold harmless Milestones Play Gym & Pediatric Therapy and all employees, contractors, sub-contractors, or volunteers past or present from any claims, suits, liabilities, judgments, costs and expenses for any property damage, loss or theft, personal injury or illness, death, or other loss arising from the use of Milestones Play Gym & Pediatric Therapy. 5. Waiver- I hereby waive any protections afforded by any statue or law in any jurisdiction whose purpose and/or effect is to provide that a general release shall not extend to claims, material, or otherwise which the person giving the release does not know or suspect to exist at the time of executing the release. I am releasing unknown future claims. 6. Payment for damages- I agree to pay for any and all damages to any property or equipment as a result of my or my family’s willful actions, neglect, or recklessness and agree to be held liable for all costs associated with such damages. 7. Representatives- I enter into this agreement for myself as well as for my heirs, assigns, and legal representatives. 8. Insurance- I understand that I am solely responsible for any medical, health, or personal injury costs related to my use of Milestones Play Gym & Pediatric Therapy and its facilities. I understand that I am strongly encouraged to have a medical physical exam and purchase health insurance prior to my use of the facilities at Milestones Play Gym & Pediatric Therapy. 9. Arbitrations- All parties to this agreement agree to mediate, in good faith, any dispute prior to initiating arbitration or litigation based on the laws of the state of Virginia. Should Milestones Play Gym & Pediatric Therapy or anyone acting on its behalf, incur attorney’s fees and costs, I agree to hold them harmless for all such fees and costs. This means I will cover all of these attorney fees and costs myself. 10. I agree to grant Milestones Play Gym & Pediatric Therapy and all related parties the irrevocable right and permission to photograph and or record me or said minor and to use the photograph/recording for all purposes, including advertising and promotions. I agree that the rights granted to this release or without compensation of any kind. All photographs/recordings are exclusive to Milestones Play Gym & Pediatric Therapy. 11. I, for myself, my child/children or ward/wards understand that my execution of this waiver on the initial visit will authorize Milestones Play Gym & Pediatric Therapy to enter this waiver into its database and use it as a continuous, multi-use waiver for my child’s/children’s ongoing participation in the activities or use it as a waiver executed for my other child/children. I hereby expressly authorize Milestones Play Gym & Pediatric Therapy to use this Waiver as a multi-use waiver until such time as I revoke it in writing. I have read and fully understand this Assumption of Risk, Waiver, and Release from Liability and understand that it relates to surrendering and releasing valuable legal rights. I do so freely and voluntarily on behalf of myself and any minor child/children for which I am the parent, legal guardian, or otherwise responsible for, named below.

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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.


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*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
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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