ACRO
TUCKS
HANDSPRINGS
Waiver Form
Must be filled out by legal guardian

 

Waiver must be filled out completely or child will

not be able to participate

KIDZONE, INC.   Waiver and Liability Release Form

Today’s Date_____________Name of class/activity______________

 

Name: _______________________  Age:     ____

Date of Birth: ______________________   Phone: _____________

Address: ______________________________________________ 

City _____________  NJ,  Zip Code: ___________

Emergency Contact: _______________Relationship: __________

Phone Number: ________________________________

Emergency Phone Number: __________________________

Please print clearly

Email_____________________________________________

 

 

In consideration of being allowed to participate in any way at KIDZONE, Inc. athletic/ gymnastic/ sports programs, related events and activities, the undersigned acknowledges, appreciates, and agrees that:

1.          The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and

2.          I knowingly and freely assume all such risks, both known and unknown, even if   arising from the negligence of staff employees, agents, and representatives of KIDZONE, Inc. or others and assume full responsibility for my participation or that of my minor child or ward for whom I am signing for as legal guardian of a minor; and

3.          I willingly agree to comply with the stated and customary terms and conditions for  participation. If however, if I observe any unusual significant hazard during my presence or  participation, I may remove myself or a minor who I have signed for from participation and bring such to the immediate attention of nearest staff employee; and

4.          I, for myself, or my minor child/ward and on behalf of my heirs, assigned, personal     representatives and next of kin, herby release and hold harmless KIDZONE, Inc., their officers, staff employees, agents, other participants, sponsoring agencies, sponsors, advertisers, and,  if applicable, owners and lessors of said premise used to conduct the event, (collectively the releasees”), with respect to any and all injury disability, death or loss or damage to person or property, whether arising from the negligence of the releasees or otherwise.

5.          This is to certify that I, with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the releasees, and, for myself, any heirs,   assigns, and next of kin, I release and  agree to indemnify and hold harmless the       releasees from any and all liabilities incident to the involvement or participation of my minor child in these programs as provided above. I agree to this even if injury or death arises from the negligence of the releasees. This release is absolute and to the fullest extent permitted by law. I further certify that I have health insurance coverage on myself, or my minor child/ward, and the coverage will remaining in full force and effect during the period I, or my child/ward remains enrolled with KIDZONE, Inc. I understand that the failure of KIDZONE, Inc. to verify this information does not waive my responsibility to comply.

 

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, I FULLY UNDERSTAND THE TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS WAIVER, AND SIGN IF FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

 

Signature: __________________  Print:____________________  Date: _____

 

Health Insurance Provider _________________________________________ 

Policy # __________________________________ Exp. Date_____________