Signature: X ...



-912495244475Step 1. Family Information / Parent / Guardian / Billing ContactParent/Guardian First & Last Name: ____________________________________________________________________Address: __________________________________________________City:________________________________State:__________Zip:__________Phone #1 Name & Number: ________________________________________________Phone #2 Name & Number: ________________________________________________ E-Mail: ____________________________________________ EMERGENCY CONTACT Name & Number: _________________________________________________________#__________________________________________00Step 1. Family Information / Parent / Guardian / Billing ContactParent/Guardian First & Last Name: ____________________________________________________________________Address: __________________________________________________City:________________________________State:__________Zip:__________Phone #1 Name & Number: ________________________________________________Phone #2 Name & Number: ________________________________________________ E-Mail: ____________________________________________ EMERGENCY CONTACT Name & Number: _________________________________________________________#__________________________________________1606556350 *Must be filled out before participation can begin*00 *Must be filled out before participation can begin*-948055-12763500 5183505128270Revised 6/26/2000Revised 6/26/20-914400168275Step 2. Participant Information1st Participant Name: ______________________________Birthday:________/________/_________2nd Participant Name: ______________________________Birthday:________/________/_________3rd Participant Name: ______________________________Birthday:________/________/_________Special Medical Conditions/Allergies/Restrictions: 00Step 2. Participant Information1st Participant Name: ______________________________Birthday:________/________/_________2nd Participant Name: ______________________________Birthday:________/________/_________3rd Participant Name: ______________________________Birthday:________/________/_________Special Medical Conditions/Allergies/Restrictions: -904875269875ASSUMPTION OF RISK, WAIVER OF LIABILITY: As legal guardian and/or one of the above named persons and/or participants, I recognize that potentially severe injuries, including permanent paralysis or death can occur in sports or activities involving height or motion, including but not limited to inflatable’s, gymnastics, tumbling, cheerleading, clinics, camps, private lessons, birthday parties, birthday party guests, bring a friend, open gyms, field trips, swimming, competitions, preschool, group activities, parents night out, trampoline, dance, circuit training, Zumba, running, parkour, free weights, conditioning, obstacle courses, personal training and group fitness. I AGREE TO NOTIFY KIDS ENERGY ZONE OF ANY FOOD ALLERGIES as we serve food for summer camps and/or class celebrations.Being fully aware of these dangers, I voluntarily consent to the aforementioned persons, including myself, participating in any and all programs at Great Lakes Kids Energy Zone and I ACCEPT ALL RISKS associated with that participation. In consideration for allowing my child and/or myself to use this facility, I, on my own behalf and the behalf of my child and our respective heirs, administrators, executors, and successors, hereby COVENENT NOT TO SUE and FOREVER RELEASE Great Lakes Kids Energy Zone, its officers, directors, shareholders, employees or other representatives, whether paid or volunteer, from all liability for any and all damages or injuries/illness suffered by myself or my child while on the premises, under the instruction, supervision or control of Great Lakes Kids Energy Zone. I also understand that it is the responsibility of the legal guardian and/or the above named persons to warn the participant and/or be aware of the dangers of injury/illness. The guardian is aware and should warn the participant according to what the guardian feels is appropriate. Great Lakes Kids Energy Zone will only warn the participant thru safety messages and our teaching style and progressions.PERMISSION FOR USAGE OF PHOTOGRAPHS AND VIDEOS: I also understand and give permission for photographs and videos of named persons and/or participants and/or myself be used in print or broadcast media as deemed appropriate for the promotion of Great Lakes Kids Energy Zone.PERMISSION FOR EMERGENCY MEDICAL TREATMENT/MEDICAL INSURANCE:I confirm that the above named persons and/or participants are in good health and I have medical insurance and will provide coverage while named persons and/or participants are enrolled. I fully understand that Great Lakes Kids Energy Zone staff members are not physicians or medical practitioners of any kind. With the above in mind, I hereby release Great Lakes Kids Energy Zone staff members to render temporary first aid to named persons and/or participants in the event of any injury or illness, and if deemed necessary by the Great Lakes Kids Energy Zone staff to seek medical help including calling of an ambulance for said named persons and/or participants should the Great Lakes Kids Energy Zone staff deem this to be necessary. Additionally, I hereby agree to individually provide for all medical expenses, which may be incurred by named persons and/or participants as a result of any injury or illness, including Covid-19, sustained while participating at Great Lakes Kids Energy Zone.00ASSUMPTION OF RISK, WAIVER OF LIABILITY: As legal guardian and/or one of the above named persons and/or participants, I recognize that potentially severe injuries, including permanent paralysis or death can occur in sports or activities involving height or motion, including but not limited to inflatable’s, gymnastics, tumbling, cheerleading, clinics, camps, private lessons, birthday parties, birthday party guests, bring a friend, open gyms, field trips, swimming, competitions, preschool, group activities, parents night out, trampoline, dance, circuit training, Zumba, running, parkour, free weights, conditioning, obstacle courses, personal training and group fitness. I AGREE TO NOTIFY KIDS ENERGY ZONE OF ANY FOOD ALLERGIES as we serve food for summer camps and/or class celebrations.Being fully aware of these dangers, I voluntarily consent to the aforementioned persons, including myself, participating in any and all programs at Great Lakes Kids Energy Zone and I ACCEPT ALL RISKS associated with that participation. In consideration for allowing my child and/or myself to use this facility, I, on my own behalf and the behalf of my child and our respective heirs, administrators, executors, and successors, hereby COVENENT NOT TO SUE and FOREVER RELEASE Great Lakes Kids Energy Zone, its officers, directors, shareholders, employees or other representatives, whether paid or volunteer, from all liability for any and all damages or injuries/illness suffered by myself or my child while on the premises, under the instruction, supervision or control of Great Lakes Kids Energy Zone. I also understand that it is the responsibility of the legal guardian and/or the above named persons to warn the participant and/or be aware of the dangers of injury/illness. The guardian is aware and should warn the participant according to what the guardian feels is appropriate. Great Lakes Kids Energy Zone will only warn the participant thru safety messages and our teaching style and progressions.PERMISSION FOR USAGE OF PHOTOGRAPHS AND VIDEOS: I also understand and give permission for photographs and videos of named persons and/or participants and/or myself be used in print or broadcast media as deemed appropriate for the promotion of Great Lakes Kids Energy Zone.PERMISSION FOR EMERGENCY MEDICAL TREATMENT/MEDICAL INSURANCE:I confirm that the above named persons and/or participants are in good health and I have medical insurance and will provide coverage while named persons and/or participants are enrolled. I fully understand that Great Lakes Kids Energy Zone staff members are not physicians or medical practitioners of any kind. With the above in mind, I hereby release Great Lakes Kids Energy Zone staff members to render temporary first aid to named persons and/or participants in the event of any injury or illness, and if deemed necessary by the Great Lakes Kids Energy Zone staff to seek medical help including calling of an ambulance for said named persons and/or participants should the Great Lakes Kids Energy Zone staff deem this to be necessary. Additionally, I hereby agree to individually provide for all medical expenses, which may be incurred by named persons and/or participants as a result of any injury or illness, including Covid-19, sustained while participating at Great Lakes Kids Energy Zone.center3919855925 N. Lapeer Road Suite 318 Oxford, MI 48371248.236.9600 00925 N. Lapeer Road Suite 318 Oxford, MI 48371248.236.9600 -9144001572895Step 3. Installment Billing & Covid-19 Parent Safety Agreement Information (This is a binding agreement.) ______I authorize AUTOMATIC installment billing. I authorize GLKEZ to charge my credit/debit card on file the 1st of each month for my balance due and e-mail me my receipt. Auto billing only applies to programs that have installment monthly tuition (weekly classes, team tuition, competition fees, etc). I can cancel auto billing by speaking to office staff by the LAST day of the month you wish to remain enrolled in. There are no refunds or credits issued once tuition has been run on the 1st. _____ I understand and agree to all of the terms in the Covid-19 Parent Safety Agreement, and have received a copy for my records. 00Step 3. Installment Billing & Covid-19 Parent Safety Agreement Information (This is a binding agreement.) ______I authorize AUTOMATIC installment billing. I authorize GLKEZ to charge my credit/debit card on file the 1st of each month for my balance due and e-mail me my receipt. Auto billing only applies to programs that have installment monthly tuition (weekly classes, team tuition, competition fees, etc). I can cancel auto billing by speaking to office staff by the LAST day of the month you wish to remain enrolled in. There are no refunds or credits issued once tuition has been run on the 1st. _____ I understand and agree to all of the terms in the Covid-19 Parent Safety Agreement, and have received a copy for my records. 1803403459480I have read and completely understand all terms and conditions of this agreement.00I have read and completely understand all terms and conditions of this agreement.-9620253409315Signature: X____________________________________________________Date___________00Signature: X____________________________________________________Date___________-819150330390500RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK; AND INDEMNITY AGREEMENT I represent that I understand the nature of this activity and that I am qualified, in good health and in proper physical condition to participate in such activity. I acknowledge that if I believe event conditions are unsafe or I am unable to safely perform any activity, I will immediately discontinue participation in the activity. I fully acknowledge, understand, appreciate and agree, that this activity involves risks of serious bodily injury, including permanent disability, paralysis and death, which may be caused by my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the Releasees named below; and that there may be other risks either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, cost, and damages I incur as a result of my participation in the activity. I further acknowledge, understand, appreciate and agree that my participation may result in possible exposure to and illness from infectious diseases, including, but not limited to, MRSA, Influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my participation and exposure. I hereby release, discharge, and covenant not to sue your business, it's administrators, directors, agents, officers, volunteers, employees, contractors, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of the premises on which the activity takes place, (each considered one of the “RELEASEES” herein) from all liability, claims, demands, losses, damages, on my account caused or alleged to be caused in whole or in party by the negligence of the RELEASEES or otherwise, including negligent rescue operations and further agree that if, despite this release, waiver of liability, and assumption of risk, I or anyone on my behalf, makes a claim against any of the RELEASEES, I will indemnify, defend, and hold harmless each of the RELEASEES from any loss, liability, damage, or cost, which any may incur as the result of such a claim. I have read the RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, and I understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law. I agree that if any portion of this Agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect. Printed name of participant(s) ___________________________________________________________ PARENTAL CONSENT I, hereby covenant and promise that I am the minor’s parent and/or legal guardian, and on behalf of myself and the minor, understand the nature of the above referenced activities and the minor’s experience and capabilities and believe the minor to be qualified to participate in such activity. I further understand the risk of exposure to injury and/or infectious diseases, for myself and my child, as a participant, spectator at events, classes or our presence at the facility. I hereby release, discharge, covenant not to sue and AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS each of the RELEASEES from all liability, claims, demands, losses or damages on the minor’s or my account caused or alleged to have been caused in whole or in part by the negligence of the Releasees or otherwise, including, but not limited to injury, negligent rescue operations, and/or exposure to infectious diseases and I further agree that if, despite this release, I, the minor, or anyone on the minor’s behalf makes a claim against any of the above RELEASEES, I WILL DEFEND, INDEMNIFY, AND HOLD HARMLESS each of the RELEASEES from any litigation expenses, attorney fees, loss liability, damage, or cost which any RELEASEE may incur as the result of any such claim. Dated: __________________________ Printed Name of Parent/Legal Guardian _________________________________________ Signature of Parent/Legal Guardian __________________________________________ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download