Waiver of Liability and Permission to Use Pictures

THIS REGISTRATION is ONLY used if you are a NEW Customer. If you are already in our database, then please do NOT submit this form!

Go to: Kidsville Recurring Membership Agreement

I am the parent/legal guardian of the Child/Children named below or I have obtained permission from the parent/legal guardian of the Child/Children named below to sign this agreement on their behalf. I give permission and accept full responsibility for the Child/Children to participate in the activities at KIDSVILLE PLAYGYM (“Kidsville”). As a Condition to the Child’s/Children’s participation in the activities and by signing this form, I acknowledge and agree that: The operator(s) have advised me that there is GYMNASTICS EQUIPMENT THAT IS DANGEROUS WITHOUT ADULT SUPERVISION; the Child/Children and I are solely responsible for deciding whether or not to participate or to rely upon any instructions, advice, or information regarding the activities; it is not Kidsville’s responsibility to teach safety before, during or after participation and use of the structures; I am solely responsible for the decision to allow the Child/Children to participate and use the structures; I am of legal age and mental competence to knowingly give this acknowledgment and release which shall legally bind me and the Child/Children and our personal representatives, executors, heirs, and assigns. I hereby give permission for myself/my child(ren) to be transported to a medical facility in the case of a medical emergency. I give permission for Kidsville staff to assist my child(ren) in the restroom and/or change his/her diaper if needed. If someone other than the undersigned is to pick up my child(ren) I give Kidsville permission to release my child(ren) to another adult I have appointed. Kidsville will not be held liable for children after they have left the premises.

I, the undersigned, give permission for the use of any photos, movies, and audio or video tapings of my child's activities at Kidsville. The material so obtained may be employed with Kidsville's approval for marketing purposes, media coverage or for publicity benefiting our facilities. I HEREBY RELEASE AND WAIVE, ANY AND ALL CLAIMS , KNOWN AND UNKNOWN, THAT THE CHILD/CHILDREN OR I MAY NOW OR LATER HAVE AGAINST KIDSVILLE, ITS MEMBER(S), EMPLOYEE(S), INSTRUCTOR(S), OPERATOR(S) AGENTS, OR REPRESENTATIVES RELATED TO ANY ACT, OMISSION, STATEMENT, OR OCCURRENCE DURING OR RELATED TO THE USE OF THE STRUCTURES OR THE FACILITY, FOR , LIABILITY FOR DIRECT, INDIRECT, VICARIOUS, PUNITIVE AND ANY OTHER DAMAGE WHETHER SUCH PARTY WAS INFORMED OR WAS AWARE OF THE POSSIBILITY OF SUCH LOSS OR DAMAGE.

Child's Information - Please complete this Form for up to 3 Children. If you have more than 3 children to register, please complete another form for additional children. All people who enter the facility (even infants) must be named on this form.

Child First Name and Last Name *

Birth Date * +

Child 2 First Name and Last Name

Birth Date +

Child 3 First Name and Last Name

Birth Date +

Parent's Information

First Name *

Last Name *

E-Mail Address *

Phone Number *

Street Address *

City *

State *

Zip Code *

Emergency Contact

First Name and Last Name *

Phone Number *

Other people authorized to pick up your child at Kidsville Playgym

First Name and Last Name

Allergies/Notes? *

Please check the box below to indicate your agreement with the above Waiver, Terms and Conditions.

I Agree!

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