Waiver Acknowledgment Form
This Waiver Acknowledgement Form is designed to confirm that you have reviewed and understood the applicable waiver(s) and to document your voluntary agreement to the terms therein. *Please select the specific waiver form that applies to your situation from the option provided. *Indicate the state or jurisdiction relevant to the waiver, if required. *By submitting your electronic signature, you acknowledge that it has the same legal effect as a traditional ink signature. *Your signature confirms that you have read, understood, and agreed to the terms and conditions of the selected waiver. *By proceeding with the selected waiver and providing your electronic signature, you acknowledge and agree that: You the terms of the selected waiver in full. You understand the rights, responsibilities, and potential risks described in the waiver. You voluntarily consent to be bound by the waiver terms as if you had signed a physical copy. You affirm that the information you provided is accurate and complete to the best of your knowledge.
1. What state is this waiver for (jurisdiction)?
Colorado
Iowa
2. What program is this waiver for?
Awareness Bound
Sole Connection
3. Name and Date of Birth of Individual Filling Out the Form:
4. Address of Facility or Current Residence:
5. Contact Email:
6. Are you the legal age of 18 or older??
Yes
No
7. If you are under the age of 18 and signing for yourself, are you LEGALLY emancipated?
Yes
No
8. If you are 18+, indicate your role (select all that apply):
Parent/Guardian
Program/Facility Manager
Manager or Director+
Other - Please clarify your role in question 10
9. If you are the parent/guardian or acting on behalf of a minor, please provide the minor’s name and date of birth
10. If you selected "other" in question 8, Please specify your role below:
11.For program facilitators listing youth or adult participants in your care, please provide the following for each participant: **Last Name, First Initial **Date of Birth (MM/DD/YYYY) ** Shoe Type (F) = Female, (M) = Male **Shoe Size + Width: (R) = Regular, (W) = Wide, (N) = Narrow, ** Please indicate if you need a slip on shoe (S) = Slip-on/No-tie Example: Smith, C 12/12/2015 F6RS (non-slip work shoe)
12. Shoe Type / Purpose: Example: Non-slip work shoe
13. Awareness Acknowledgment: ** I understand that participation in the program is voluntary. **I acknowledge that the participant’s safety and well-being are the responsibility of the instructor, and I will inform the instructor of any food allergies or medical considerations as applicable. **Parents/Guardians must inform the instructor of any allergies, sensitivities, or medical conditions relevant to participation. Program facilitators initial for the all classmates OAA is teaching. **Please Initial below
14. I have reviewed the selected waiver terms and understand your rights, responsibilities, and potential risks??
Please Select
I have reviewed the selected waiver
15. I consent to electronic signature and acknowledge its legal equivalence to an ink signature.
Please Select
I do consent to an electronic signature
16. I have verified that all required fields are completed accurately
Please Select
I have verified accuracy of the required fields
17. Please type your full name and date of signature (YYY-MM-DD) as an electronic signature: By typing my name and submitting this form, I acknowledge that the information provided is true and complete to the best of my knowledge. I acknowledge that I have read and understood the waiver terms and accept the terms and conditions as described. This waiver is good for 1 calendar year from the date of signature.
Submit
Should be Empty: