Tigers & Tots Indoor Playground Registration

Tigers & Tots Indoor Playground Registration
Child Full Name:*

First NameLast Name
Nickname:
Age:
Date of Birth:*

MonthDayYear
Date
Gender:*
Parent/Guardian 1 Full Name:*

First NameLast Name
Parent/Guardian 1 Phone Number:*
Please enter a valid phone number.
Parent/Guardian 1 Email:*
example@example.com
Parent/Guardian 2 Full Name:

First NameLast Name
Parent/Guardian 2 Phone Number:
Please enter a valid phone number.
Parent/Guardian 2 Email:
example@example.com

WAIVER OF LIABILITY, INDEMNIFICATION, AND MEDICAL RELEASE

I am aware of the dangers and the risks to myself, my child, and/or any child whose care I have been entrusted with, that is posed by the Tigers & Tots Indoor Playground, the LSU Health Sciences Center New Orleans School of Allied Health Professions Indoor Playground area for children ages 0-3 to our persons and property.

I understand that activity by myself, my child, and/or any child whose care I have been entrusted with involves certain risks for physical injury, including, but not limited to: running, climbing, playing, sliding, and other forms of mild to mid activities.

I also understand that there are potential risks to myself, my child, and/or any child whose care I have been entrusted with of which I may not presently be aware. Because of the dangers of participating in this activity, I recognize the importance and agree to fully comply with the applicable laws, policies, rules, and regulations and any supervisor’s instructions regarding participation in this activity.

I understand that LSU Health New Orleans does not insure participants in the above-described activity, that any coverage would be through personal insurance, and LSU Health New Orleans has no responsibility or liability for injury resulting from this activity.

I voluntarily elect to participate in this activity with the knowledge of the danger involved, and I hereby agree to accept and assume any and all risks of property damage or, personal injury to myself, my child, and/or any child whose care I have been entrusted with.

Waiver of Liability and Indemnification:

In consideration for being allowed to voluntarily participate in the above-referenced activity, on behalf of myself, my child, and/or any child whose care I have been entrusted with, I forever:

a) waive, release, and discharge LSU Health New Orleans and its agencies, officers, and employees from any and all negligence and liability for death, disability, personal injury, property damages, property theft or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced activity or event; and

b) agree to defend, indemnify, and hold harmless LSU Health New Orleans, its agencies, officers and employees, from and against any and all claims of any nature including all costs, expenses and attorneys’ fees, which in any manner result from participant’s actions during this activity or event.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident or illness during this activity or event. This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.

I, the undersigned participant, affirm that I am at least 18 years of age and am freely signing this agreement. I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my participation. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.

READ BEFORE SIGNING
PARENT/GUARDIAN SIGNATURE*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship if Not Patient (legal documentation proving relationship by the signing individual may be required):*

Legal SpouseParentLegal GuardianAdult Child of PatientHealthcare Power of Attorney/AgentOther
I, {parentguardian1}, hereby grant permission to
LSU Health Sciences Center New Orleans to photograph, video tape,
record, or interview me, or in the case of a minor, my
child {childFull}, for print, broadcast, digital,
or social media use, for use in LSU Health Sciences Center New Orleans
publications, advertising or promotion, video or audio tapes, brochures,
website, social media, conferences, or for use in teaching by LSU Health
Sciences Center New Orleans faculty.

I hereby transfer to LSU Health Sciences Center New Orleans all rights
and claims I have, or in the future may acquire, with respect to such
photographs, video recordings, audio recordings, and/or written materials,
agreeing that same shall be the sole and absolute property of LSU Health
Sciences Center New Orleans. I hereby relieve and release LSU Health
Sciences Center New Orleans from any and all claims whatsoever, and for
any and all kinds of remuneration for use of such materials.
Signature*

Clear
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
After submission, an email will be sent to book a play date.
Should be Empty: