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Release of Liability and Waiver form

In consideration for being allowed to enter into the play area and/or participate in any party and/or program at Kids in
Motion, the undersigned, on his or her own behalf, and on behalf of the participant(s) listed below, acknowledges,
appreciates and agrees to the following conditions: I represent that I am the parent or legal guardian for the
participant(s) named below, or that I have obtained permission from the parent/legal guardian of the participant(s)
named below to execute this agreement on their behalf. I further represent that the participants are healthy and
physically able to participate in any and all undertaken activities. I agree that the participant(s) named below and I
shall comply with all stated and customary terms, posted safety signs, rules and verbal instructions as conditions for
participation in any party and/or program at Kids in Motion. I agree to pay for all damages to the facilities of Kids in
Motion caused by my or my family's negligent, reckless or willful actions. I am aware there are inherent risks with
participation at Kids in Motion programs, parties, and/or use of the play area, equipment, and I, on behalf of myself
and the participant(s) listed below, knowingly and fully assume all such risks, both known and unknown, including
those that may arise out of the negligence of other participants or employees. I, for myself and the participant(s) named
below and our respective heirs, assigns, administrators, personal representatives and next of kin, hereby release and
hold harmless Kids in Motion, Inkwell Creations LLC, the management, their affiliates, officers, members, agents,
employees, other participants and sponsoring agencies from and against any and all claims, injuries, liabilities or
damages arising from or related to our participation in any and all Kids in Motion programs, activities, parties, the use
of play area and all Kids in Motion equipment. With admission, you give permission to Kids in Motion for the use of
photographs and/or video of yourself and your dependents. Please notify the front desk if you do not consent to this
policy. Email (optional)_____ Yes, I would like to receive updates and promotional information from Kids in Motion.

Parent/GuardianName:___________________________________________Signature:____________________________________
Address:______________________________________________________________City:___________________________________
Zip:_____________Home Phone#:_________________________________________________
Email:____________________________________________________________________

Participant's Name:_____________________________________________birthdate___/___/___
Participant's Name:_____________________________________________birthdate___/___/___
Participant's Name:_____________________________________________birthdate___/___/___
(Use bottom or back of page to add additional children)

Emergency Contact:________________________________________________ Telephone #:________________________________
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