Replace this text with your company's privacy policy.
Loading...

Play and Ponder – Parent’s Date Night Waiver & Release of Liability

Event Location: Play and Ponder, Portland, OR 97229

Event Name: Parent’s Date Night (Drop-Off Program for Kids Ages 3–10)

Event Time: Thursdays, 5:00 PM – 8:00 PM

Terms and Conditions

1. Program Overview:

I acknowledge that I am voluntarily enrolling my child(ren) in the Parent’s Night Out program at Play and Ponder. I understand this is a drop-off event where children are under the supervision of background-checked, CPR-certified staff and/or camp-certified coordinators.

2. Potty Training Requirement:

I certify that my child is fully potty trained. Play and Ponder reserves the right to contact me for early pickup if my child is unable to manage bathroom needs independently.

3. Health and Safety:

I confirm that my child is in good health and is physically able to participate in activities. I agree not to bring my child if they are experiencing symptoms of illness, including but not limited to fever, cough, vomiting, or diarrhea.

I understand that while Play and Ponder takes all reasonable precautions, they are not liable for illness, including communicable diseases such as colds, flu, or COVID-19.

4. Medical Treatment Authorization:

In the event of a medical emergency, I authorize Play and Ponder staff to provide necessary first aid and to seek medical treatment for my child if I cannot be reached on time. I agree to be responsible for all medical expenses incurred.

5. Insurance Disclosure:

I acknowledge that Play and Ponder does not provide medical insurance for participants. I certify that my child is covered by personal health insurance, and I accept full responsibility for any costs related to injuries or medical treatment.

6. Liability Waiver & Release:

I, the undersigned, understand and acknowledge that participation in any indoor play or group activity involves inherent risks, including minor injuries such as bruises or scrapes, as well as more serious risks.

I hereby release, waive, discharge, and hold harmless Play and Ponder, its owners, employees, contractors, volunteers, and affiliates from all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, or injury, including death, that may be sustained by my child(ren) while participating in this program.

7. Property Damage:

I agree to be financially responsible for any intentional or negligent damage caused by my child to Play and Ponder’s property or that of other guests.




First Parents Name
First Name*
Middle Name
Last Name*
Phone*
First Parents Date of Birth*
Date of Birth
First Parents Signature*
Second Parents Name
First Name*
Middle Name
Last Name*
Parents Date of Birth*
Date of Birth
Third Parents Name
First Name*
Middle Name
Last Name*
Parents Date of Birth*
Date of Birth
Fourth Parents Name
First Name*
Middle Name
Last Name*
Parents Date of Birth*
Date of Birth
Fifth Parents Name
First Name*
Middle Name
Last Name*
Parents Date of Birth*
Date of Birth
Sixth Parents Name
First Name*
Middle Name
Last Name*
Parents Date of Birth*
Date of Birth
Seventh Parents Name
First Name*
Middle Name
Last Name*
Parents Date of Birth*
Date of Birth
Eighth Parents Name
First Name*
Middle Name
Last Name*
Parents Date of Birth*
Date of Birth
Ninth Parents Name
First Name*
Middle Name
Last Name*
Parents Date of Birth*
Date of Birth
Tenth Parents Name
First Name*
Middle Name
Last Name*
Parents 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.
Media Release
Click to customize checkboxes
I give permission for my child to be photographed or video recorded for Play and Ponder marketing or social media purposes.
I do not give permission.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Any allergies or medical condition we need to be aware of?

Please mention in details.

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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!