Veteran Program

Shake-A-Leg Miami

Veteran Program Application

* required Information

Date *

MonthDayYear

Veteran *

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date of Birth*

MonthDayYear

Gender*

FemaleMale

Veteran with Disabilities*

YesNo

Which Military Department have you served in*

Mobile Number*

Area CodePhone Number

Email Contact*

Emergency Contact*

Emergency Phone*

Area CodePhone Number

Can you swim?*

Medical Conditions/ Allergies

Activity Interest

Have You Visited Shake A Leg Before*

YesNo

If answered yes above please specify *

General Waiver of Liability
In consideration of Shake-A-Leg Miami, Inc. (“SALM”) extending to me the
opportunity to perform services for, utilize services of, participating in programs
provided by SALM, I fully assume all risks that might arise, both known or
unknown, and both inherent to the program or activity in which I am engaging and
any risks that are not inherent, and waive all liability for all such risks, including
without limitation any potential liability that SALM may have for its own
negligence or the negligence of any of its agents, officers, directors, or employees,
in connection with my participation in the program or activity, and in particular,
without limitation, to the extent permitted by law, I and my heirs, representatives,
executors, or administrators and my undersigned parent, guardian or aide (if
applicable) remise, release, indemnify, acquit and hold harmless and forever
discharge SALM and its directors, officers, employees, agents, instructors,
volunteers, rescue and support personnel, from any and all claims and liability,
including without limitation liability for SALM’s and its directors’, officers’,
employees’, agents’, instructors’, volunteers’, rescue and support personnel own
negligence, and all obligations, damages, claims, causes of action, judgements,
costs and charges which I may suffer or which may be incurred by me for any
reason of any occurrence during my travel to and from the activity or program, and
during my participation therein, whether resulting from any acts, omissions or
negligence or from acts of God or nature. I also agree to assume liability for all
and any damages to SALM property that I intentionally or recklessly cause or that
I cause due to my gross negligence while participating in any SALM activity.
During my participation, I hereby agree to comply with all SALM rules and
regulations, applicable county and municipal ordinances, and with the laws of the
State of Florida and the United States. I understand that photos, videos, and
images of me and my participation in the SALM Program or activity may be
considered educational records under federal law and may not be disclosed
without my consent. Photos, videos, or images of me alone; photos, videos or
images of our group participation, that include me; and/or anything else that
identifies my likeness, image, name, address or location, shall not be used in any
media story, promotion, advertisement, or account of a SALM related program
without my specific authorization.
CHOICE OF LAW: I understand and agree that the law of the State of
Florida will apply to this contract.

Veteran Signature*

I hereby give my full and unconditional permission to SALM for the free use of my and the Camper's name, likeness, and image (including without limitation permission to use any photo and video in which I may appear) in any present or future media story, promotion, advertisement, or account of an SALM related program, event, or activity, including without limitation in connection with any present or future public relations or fundraising event or activity.

YesNo

Type a question