WAIVER OF LIABILITY, CONSENT TO MEDICAL TREATMENT, & PUBLICITY RELEASE
1. Participation in Activities
The Warehouse is owned and operated by Realife Media, Inc., an Indiana non-profit corporation. This document shall govern all activities conducted at The Warehouse, 1525 South Rogers Street, Bloomington, Indiana. As the participant named above, or as the parent/guardian of the participant named above, I hereby give my permission for my child to participate in any activities at The Warehouse.
2. Release of Liability
I, for myself, my minor child and for the child’s other parent and/or guardian, hereby release, waive, discharge, and covenant not to sue The Warehouse, Realife Media, Inc., any non-profit partner of The Warehouse ("The Warehouse Organizations"), and their members, officers, directors, trustees, employees, agents, volunteers, heirs and assigns of and from all liability, loss, claims, demands, and possible causes of action arising from any loss, damage or injury to me or to my child’s person or to our property in any way resulting from or connected with my or my child’s participation in any activities conducted at The Warehouse, including, without limitation, the failure of anyone to enforce rules and regulations, failure to make inspections, or the negligence of other persons.
3. Assumption of Risk
I know that many of the activities at The Warehouse involve the risk of physical harm. I know there are potential risks and dangers to myself, to my child and to our property, both from known risks and unanticipated risks, while participating in the activities at The Warehouse. I participate in, and I give permission for my child to participate in, such activities willingly, voluntarily and in reliance upon my own judgment and ability, and I thereby assume all risk of loss, damage or injury (including death) to myself, to my child and to our property from any cause whatsoever and whether or not caused by the negligence of others.
4. Consent to Medical Treatment
In the event that I, or my child, become ill or injured, I give my permission for a representative of The Warehouse to take whatever steps are reasonably necessary to render emergency first aid to me or to my child. I also consent to such emergency medical treatment as may be reasonably necessary to insure the health and welfare of me or my child including, but not limited to, x-rays, anesthetic, medical or surgical diagnosis and treatment, hospital care and administration of drugs or medicine under the care of a licensed physician and/or surgeon.
5. Publicity & Photo Release.
I hereby grant to The Warehouse Organizations the absolute and irrevocable right and unrestricted permission to use my and that of my child, our likeness, image, voice, and/or appearance as such may be embodied in any photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of The Warehouse Organizations. I agree that The Warehouse Organizations have complete ownership of such material and can use said material for any purpose consistent with their missions. These uses include, but are not limited to, videos, publications, advertisements, news releases, Internet sites, and any promotional or educational materials in any medium. I acknowledge that neither I nor my child will receive any compensation for the use of such images, video, likeness, etc.
First Name of Participant
Last Name of Participant
Participant's Date of Birth (MM/DD/YYYY)
Participants Phone Number (No Dashes, i.e 8121234567)
Emergency Contact Name and Phone Number
Name of Parent/Guardian if this form is for a minor.
By checking this box you are giving your digital signature that you the participant and/or legal guardian agree to all the above terms and conditions:
(Please sign below after printing)
Never submit passwords through Google Forms.
This form was created inside of The Warehouse.