PRESTIGE POLE AND MOVEMENT LLC
WAIVER AND RELEASE OF LIABILITY FORM
This is a release of liability and a waiver of your legal rights
PLEASE PRINT—You must fill out form completely
DATE: ____________________, 20____
Participants Full Name: {name}
Date of Birth: {dob} Age _______
Emergency Name {contact_name}/Phone {contact_phone}
I affirm and certify that I am over age 18, not under the influence of any drug or substance or subject to any physical or mental illness or defect that affects or could affect my understanding of what is presented below, and otherwise fully and legally competent to enter into this Agreement, and that I hereby agree and consent to the terms of this document freely and voluntarily.
I HEREBY release PRESTIGE POLE AND MOVEMENT LLC, it’s owners, instructors, independent contractors, and all other associates from liability for harm, theft, or injury that may be suffered by me and/or members of my family traveling to or from or during participation in activities and programs sponsored by PRESTIGE POLE AND MOVEMENT LLC. I hereby acknowledge that I am voluntarily assuming full responsibility for all risks of physical injury arising out of active participation in a pole, aerial and non-aerial class.
I acknowledge the contagious nature of COVID-19 and other contagious diseases and viruses and voluntary assume the risk that I may be exposed to or infected by COVID-19 by attending and participating. I also acknowledge that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 and other contagious diseases and viruses may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, independent contractors, volunteers, and program participants and their families. I release PRESTIGE POLE AND MOVEMENT LLC, its owners, instructors, independent contractors, and all associates from liability for harm, injury or death pertaining to COVID-19 and other contagious diseases and viruses.
I understand that if my class gets cancelled due to weather, sickness, or any issues arising from COVID-19 a class credit will be issued. Party cancellations or reschedules must occur twenty-four hours before scheduled events and deposits are non-refundable. I understand that there are no refunds issued on purchase of goods and services and studio credit may be awarded on a case by case basis for missed drop-in classes and workshops. I understand and agree to PRESTIGE POLE AND MOVEMENT LLC policies and procedures. I understand that I must execute this release form before attending any class. I give permission to PRESTIGE POLE AND MOVEMENT LLC to use my pictures and or video for advertising purposes in print, promotional videos and on the website.
I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN THIS pole, aerial or non-aerial class. including by way of example and not limitation, any risks that may arise from negligence or carelessness on my part as the participant, the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.
I certify that I am in good health and that I do not pose a health risk to the public. I certify that there are no health-related reasons or problems which preclude my participation in this activity or event. I certify that am in good health with no known injuries that restrict me from performing pole, aerial or non-aerial movement. I certify that I am not under the influence of any drug or substance or subject to any physical or mental illness or defect that affects or could affect my ability to follow instructions and safely participate in a pole, aerial or non-aerial class.
I HEREBY WAIVE, RELEASE, AND DISCHARGE PRESTIGE POLE AND MOVEMENT LLC and all divisions thereof of any and all liability and responsibility for injuries, sickness, pandemics, accidents, natural disasters and/or acts of God incurred during participation in and/or instruction of classes, workshops, private lessons, or any activity I may participate.
I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event, the following entities or persons: PRESTIGE POLE AND MOVEMENT LLC and their employees, volunteers, or the activity or event holders, activity or event sponsors, activity or event volunteers.
I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this waiver, release and registration form from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by the negligence of release or otherwise. The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.
Participant’s Signature:
Date Signed: {sign_date}
