AME & SHRED THE MIND WAIVER 22

1
Participant Name* This field is required.
First Name
Last Name
2
Participant D.O.B.* This field is required.
Day
Month
Year
3
Gender(Optional)*
*(Leave blank) press next to continue
4
Local Skatepark(or where's your regular spot?)
5
Emergency Contact Info* This field is required.The emergency contact provided must be 18+
Full Name
Phone Number
Relation
D.O.B. (ddmmyyyy)
6
I completely understand and authorise the staff of Ame & Shred The Mind (© ame art music experiment C.I.C) to act on behalf according to their reasonable judgment in any emergency requiring medical attention. I acknowledge that participation in Skateboarding carries with it a risk of physical injury, I agree that Ame & Shred The Mind (© ame art music experiment C.I.C), its agents, employees, staff, or any of its assignees or other successors in interest, shall not be liable to me or the student/participant for any injury or damage, whatsoever caused, resulting directly or indirectly from the student or my participation in Ame & Shred The Mind (© ame art music experiment C.I.C) Skateboarding lessons at any time preceding, during, or after the lesson is in session and I hereby discharge and shall indemnify Ame & Shred The Mind, its agents, employees, staff, or any of its assignees or other successors in interest, from all actions, claims, and demands the student or I may have for any such injury or damage. All medical expenses incurred will be the responsibility of the participant or the participant’s parent or guardian. I have no knowledge of any physical or mental impairment that would affect the student’s or my participation in the Skateboard lesson* This field is required.
Agree Disagree
7
Signature* This field is required.Must be signed by a parent or guardian if participant is under 18
Clear
8
Signee* This field is required.Must be signed by a parent or guardian if participant is under 18
First Name
Last Name
9
Stay in Touch...Please leave your email address if you wish to be contacted about our upcoming future events!
shredthemind@gmx.com
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