Circus Monoxide Waiver

Declaration, Waiver and Release

You must be 18 or older to sign this document.
I am

The ParticipantThe Parent or Guardian of the participant
PARTICIPANT INFORMATION
PARTICIPANT Name*

First NameLast Name
PARTICIPANT Date of Birth*

MonthDayYear
Date
PARTICIPANT Phone Number*
Please enter a valid phone number.
Are there any injuries or medical conditions that we should be aware of?
Please select the reason for signing the waiver today*

Term Class EnrolmentBirthday Party GuestSchool Holiday ProgramSchool Group ParticipantOther
PARENT / GUARDIAN INFORMATION
PARENT/GUARDIAN Name*

First NameLast Name
PARENT/GUARDIAN Email*
example@example.com
PARENT/GUARDIAN Phone Number*

Area CodePhone Number
EMERGENCY CONTACT
EMERGENCY CONTACT Name

First NameLast Name
EMERGENCY CONTACT Phone Number
Please enter a valid phone number.
In consideration for and as a condition of my participating in activities provided by Circus Monoxide (CM) hereby acknowledge that:
1. The activities undertaken by taking part in classes and events at CM involve significant risk of physical harm or personal injury including permanent disability and/or death to participants. I hereby assume the risk of such illness or injury occurring by participating in any such class or event.
2. The statement set out in paragraph 1 above constitutes a risk warning pursuant to the Civil Liability act 2002 and I willingly agree to assume all risk in participating in the activities provided by Circus Monoxide.
3. I must seek full instruction from Circus Monoxide staff prior to participating in the activities regardless of prior experience elsewhere. If I have any doubts or questions after instruction is complete, I will immediately seek further instruction from Circus Monoxide staff.
4. In the event that I feel I, or any person under my care or supervision, is in difficulty during participation in the activities, I will stop the activity or request that the activity be stopped and seek assistance and/or advice from Circus Monoxide staff.
5. I will obey all signs and follow all safety directions given by Circus Monoxide staff.
6. I am medically fit (both physically and mentally) to undertake the activities and I am not intoxicated or under the influence of any drug or medication that may affect my mental perception, alertness, ability to learn or to respond to an emergency situation
7. I acknowledge that during all times while I am participating in the activities I do so at my own risk and I do not hold Circus Monoxide, the parent company Precarious Inc, or its employees or agents liable for any injury, loss or damage including personal injury or death that I may suffer while at or around the premises of Circus Monoxide as a result of participating in the activities or otherwise.
8. In the event of significant injury, Circus Monoxide will seek full medical care and/or call an ambulance. I give full permission for Circus Monoxide staff to contact an ambulance and I understand that this will be billed to me.
9. I understand that during my time in the facility I may be photographed or captured on video and these images may be used on promotional material for Circus Monoxide. I give my permission for Circus Monoxide to use my image in this capacity. If I do not wish for myself or my child to be photographed I will contact Circus Monoxide direct.
10. I have provided my email address above so that Circus Monoxide can email me updated information regarding activities, special events, or other information.
11. I hereby release Circus Monoxide, including its directors, contractors, agents, sponsors, employees and volunteers from and against any and all claims, demand, losses, suits, liabilities, costs, or other damages arising from any injury to, or death of myself/my son/daughter, or any other persons or damage to or destruction of property arising out of or in connection with my/my son/daughter's participation and I also indemnify Circus Monoxide against any loss, damage or claim I might suffer as a result of any of those things.
12. I warrant and certify that I am the parent or guardian of any participant under the age of 18 named above (“PARTICIPANT”). The participant is capable of taking part in the activities and has my consent to participate in the activities.
13. I have read and understood this document and agree on the participant's behalf to be bound by the conditions hereof.
I have carefully read and understood this declaration, waiver and release and having done so sign voluntarily.
Signature*

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Declaration, Waiver and Release

PARTICIPANT INFORMATION

PARENT / GUARDIAN INFORMATION

EMERGENCY CONTACT