Outdoor Program & Birthday Party Participation/Waiver

Program

Location

Name of Participant(s)

Age

Parent/Guardian Name (if under the age of 18)

Email Address

example@example.com

Contact Number:

Does the participant have any medical problems/allergies that the instructor/facilitator should be aware of? If yes- please specify:

Does the participant have any behaviors or needs that the instructor/facilitator should be aware of? If yes- please specify:

Is there anything else you would like to tell us about the participant?

PROGRAM INFORMATION:

I understand that participation in the above mentioned event, activity or program, could include activities that involve inherent risks, dangers and hazards both known and unknown, that are associated with unique movement patterns and skills. I also understand that the instructor/facilitator(s) will encourage and use safe activities that follow the current guidelines for socially distanced activities for those not living in the same household and will do everything in their power to ensure these guidelines are enforced but cannot be held liable if participants are not adhering to the rules set forth.

I understand that if the participant is feeling unwell at all, with any symptoms including: fever, cough, shortness of breath or any symptoms that have been deemed relevant by AHS, WHO or any other government organization - they should not attend the program that day. I also understand that the instructor/facilitator of the program may ask the participant to leave if such symptoms are apparent.

By signing below I agree to participation and release the organizations above from all liability, costs and damages which could arise from participation in the above named event, including exposure to COVID 19.

In consideration of being allowed to participate in the Puddle of Mud Productions program and activities, I hereby agree as follows: To waive any and all claims that I have or may have in the future against, and to release and discharge from any and all liability, Puddle of Mud Productions, it's directors, officers, employees, consultants, agents, contractors, volunteers, and representatives, and their respective successors and assigns, or any of them in connection with or participation in the Puddle of Mud Productions program, for any and all of the following: Personal injury; Death; Property damage; and/or Any other loss, damage or expense, arising from any cause whatsoever, including negligence (including, but not limited to, negligence caused by my own actions or inactions, those of others participating in the activities, the conditions in which the activities take place, or negligence of Puddle of Mud Productions), and further including the failure on the part of the Puddle of Mud Productions to take reasonable steps to safeguard or protect me from the risks, dangers and hazards of participating in Puddle of Mud Productions program and activities.

I would like to be added to Puddle of Mud Productions mailing list, and agree to having emails sent to the email address provided above.

YesNo

I hereby grant permission to Puddle of Mud Productions to use my/my child's likeness in photographs, video and in any and all of its publications and in any and all other media, whether now known or hereafter existing controlled by Puddle of Mud Productions in perpetuity, and for other use by Puddle of Mud Productions. I will make no monetary or other claim against Puddle of Mud Productions for the use of the photographs/video.

YesNo

Signature of Participant (if over 18 yrs)

Date

Name of Parent or Guardian

Date

Signature of Parent or Guardian

Witness