Waiver and Release

 

Waiver  and  Release  

  In  exchange  for  The  Urban  Chalkboard  allowing  my  child  (“Child”)  to  participate  in  activities  (“Activities”)  I  agree  to  the   following:     1.   Voluntary  Participation.    I  understand  and  confirm  that  I  am  voluntarily  allowing  my  Child  to  participate  in  the   Activities.     2.   Identification  of  Risks.    I  understand  my  Child’s  participation  in  the  Activities  may  involve  risk  of  injury  and  loss,   both  to  person  and  property.  I  also  understand  the  risk  of  injury  to  my  Child  may  include  the  possibility  of  permanent   disability  and  death.  I  understand  this  Waiver  and  Release  is  intended  to  address  all  risks  arising  out  of  or  relating  to  my   Child’s  participation  in  the  Activities,  including  risks  created  by  actions,  inactions,  or  negligence  on  the  part  of  The  Urban   Chalkboard  or  its  members,  managers,  officers,  employees,  agents,  volunteers,  successors,  or  assigns  (collectively,  the   “Representatives”),  and  that  these  risks,  may  include,  but  are  not  limited  to,  risks  created  by  the  following:     (a)   The  use  and  condition  of  The  Urban  Chalkboard’s  premises,  facilities,  and  equipment;   (b)   The  lack  or  inadequacy  of  policies,  rules,  regulations,  or  supervision  for  the  Activities;   (c)   The  failure  of  The  Urban  Chalkboard  or  its  Representatives  to  foresee  or  to  protect  me  or  my  Child  from   actions,  inactions,  or  negligence  of  any  person,  or  the  recklessness,  intentional,  or  criminal  misconduct   of  persons  other  than  those  affiliated  with  The  Urban  Chalkboard;  and   (d)   The  inadequacy  or  unavailability  of  medical  facilities  or  treatment.     3.   Assumption  of  Risk.    On  behalf  of  my  Child  and  myself,  I  assume  all  risks,  known  and  unknown,  foreseeable  and   unforeseeable,  in  any  way  connected  with  my  Child’s  participation  in  the  Activities,  and  I  accept  personal  responsibility   for  any  liability,  injury,  loss,  or  damage  in  any  way  connected  with  my  Child’s  participation  in  the  Activities.     4.   Release  and  Waiver.    On  behalf  of  my  Child  and  myself,  I  release  The  Urban  Chalkboard  and  its  Representatives   from  any  and  all  liability,  and  waive  any  and  all  claims,  for  liability,  injury,  loss,  damage,  or  expense,  including  attorneys’   fees,  in  any  way  connected  with  my  Child’s  participation  in  the  Activities,  whether  or  not  caused  in  whole  or  in  part  by   the  negligence  or  other  misconduct  of  The  Urban  Chalkboard  or  its  Representatives  (a  “Claim”).     5.   Indemnification.    I  agree  to  indemnify  and  to  hold  harmless  The  Urban  Chalkboard  and  its  Representatives  from   any  Claim  or  expense,  including  attorneys’  fees  (including  the  cost  of  defending  any  Claim  I  might  make,  or  that  might  be   made  on  my  behalf,  that  is  released  or  waived  hereby),  in  any  way  connected  with  a  Claim.     6.   Binding  Effect.    This  instrument  shall  be  binding  upon  my  Child,  relatives,  next  of  kin,  personal  representatives,   heirs,  beneficiaries,  and  assigns,  and  me,  and  inure  to  the  benefit  of  The  Urban  Chalkboard  and  its  Representatives.     7.   Medical  Treatment.    I  authorize  The  Urban  Chalkboard  and  its  Representatives  to  provide  my  Child,  through   medical  personnel  of  their  choice,  customary  medical  assistance,  transportation,  and  emergency  medical  services  should   my  Child  require  such  assistance,  transportation,  or  services  due  to  injury  or  damage  related  to  the  Activities.  This  does   not  impose  upon  The  Urban  Chalkboard  or  its  Representatives  to  provide  such  assistance,  transportation,  or  services.     8.   Severability.    If  any  provision  of  this  Waiver  and  Release  is  held  to  be  invalid  or  unenforceable,  such  invalidity  or   unenforceability  shall  not  otherwise  affect  any  other  provision  of  this  instrument.     9.   Applicable  Law.    This  instrument  shall  be  governed  in  accordance  with  the  law  of  the  State  of  Indiana.     10.   Use  of  Likeness.    Unless  declined  by  checking  the  box  below,  on  behalf  of  myself  and  my  Child,  I  grant  to  The   Urban  Chalkboard  an  unrestricted,  perpetual,  irrevocable,  non-­‐royalty  bearing,  and  transferable  right  and  license  to  use,   transmit,  distribute,  display,  and  otherwise  utilize  my  Child’s  image  and/or  likeness,  as  captured,  photographed,  or   otherwise  memorialized  in  connection  with  the  Activities,  in  any  medium  or  format,  for  any  purpose  whatsoever.     I  do  not  give  permission  for  The  Urban  Chalkboard  to  use  my  Child’s  image  and/or  likeness.  

    I  have  read  this  Waiver  and  Release.    I  understand  that  I  have  given  up  substantial  rights  by  signing  it.    I  am  signing  this   Waiver  and  Release  voluntarily.     In  exchange  for  my  child  being  allowed  to  participate  in  the  Activities,  and  as  the  parent(s)  or  legal  guardian(s)  of  the   below-­‐named  Child,  I  verify  that  I  fully  understand,  agree  to,  and  accept  all  provisions  of  this  Waiver  and  Release.                   Printed  Name  of  Parent/Guardian     Signature  of  Parent/Guardian     Date                   Phone  number     email  address             The  names  and  birthdates  of  my  children  participating  in  the  Activities  are  as  follows:               Name     Birthdate       Male   Female               Name     Birthdate       Male   Female               Name     Birthdate       Male   Female               Name     Birthdate       Male   Female               Name     Birthdate       Male   Female     IMPORTANT  NOTES:     Please  provide  the  name  and  telephone  number  of  someone  whom  we  may  contact  in  the  event  of  an  emergency:               Name     Telephone  number       Please  provide  any  relevant  medical  information  (e.g.,  allergies):