Open Play Registration/ Code of Conduct / Assumption of Risk Waiver and Release

Please Review and Sign Prior to Open Play

Open Play Registration

Child/Children name (s) and age who will be participating in Open play at Thriving Tots Therapy

Parent/ Guardian Name (s):

Parent / Guardian Code of Conduct – Thriving Tots Therapy Open Play

 I am aware of my child’s diagnosis/ medical condition and the physical precautions and/ or limitations before assisting my child onto a gym feature ( for example, zip line, trampoline ) and have included their precautions in their initial intake/registration forms and am willingly allowing them to play at Thriving Tots Therapy.

• I am aware and understand the risks included with movements such as jumping, spinning, running and climbing (for example some children may experience seizures with certain movements).

• I will supervise my child at all times to ensure their safety and the safety of others (for example if my child occasionally hits, bites etc.)

• I understand that all personal information shared with an employee of Thriving Tots Therapy regarding my child is kept confidential and will not be shared with other individuals.

• I understand that employees of Thriving Tots Therapy are mandated reporters of child abuse.

• I will take shoes off on gym equipment unless needed for support and safety such as with orthotics.

• I understand that siblings are allowed use of the equipment if each child also has a signed liability waiver.

• I will wash/sanitize my hands prior to use of gym equipment.

• I will sign in and out and abide by the rules that pertain to time frame and cost.

Assumption of Risk, Waiver and Release from Liability Thriving Tots Therapy Open Play

1. Risk factors – I understand and acknowledge that the use of the facilities at Thriving Tots Therapy  involves risks including, but not limited to the following: any type of bodily injury including but not limited to permanent disability, paralysis, and death. These risks may result from a variety of circumstances including the misuse of equipment or facilities and supervision as well as other children and adults and any other patrons of Thriving Tots Therapy. I have read and understand the above paragraph _____

2. Assumption of Risk – I am choosing to use the facilities at Thriving Tots Therapy at my own risk as well as my child(ren’s). Thriving Tots Therapy makes no warranties or representations as to the safety of use of facilities and/or participation in any activities at Thriving Tots Therapy. I acknowledge that it is my sole responsibility to

supervise my child(ren) while using the facilities at Thriving Tots Therapy and that Thriving Tots Therapy does not offer supervision of children. I assume full responsibility for all risks all activities, including equipment, supplies, and supervision that may arise from using the facilities Thriving Tots Therapy or from participating in activities Thriving Tots Therapy and relieve Thriving Tots Therapy from any such responsibility. I understand that I am solely responsible for any medical, health or personal injury costs relating to my use Thriving Tots Therapy and its facilities. I have read and understand the above paragraph __

3. Acknowledgement of Policies and Procedures – I acknowledge that I have read, know, and agree to all the policies and procedures relating to the use of the facilities at Thriving Tots

Therapy. I agree to comply with all rules, regulations, and policies at Thriving Tots Therapy. I understand Thriving Tots Therapy reserves the right to revoke or terminate my use of the facilities at Thriving Tots Therapy, for any violation of rules, regulations or

policies. I have read and understand the above paragraph ____

4. Release, Indemnify, and Defend – I hereby release, waive, discharge, and hold harmless and agree to indemnify Thriving Tots Therapy and all volunteers, employees, officers, and independent contractors past or present from any damage including but not limited to, claims, suits, liabilities, judgments, costs and expenses for any property damage, loss or theft, personal injury or illness, death, disease, medical expenses, and any other losses whatsoever

arising from the use of Thriving Tots Therapy .I have read and understand the above paragraph ____

5. Prerequisite skills – I acknowledge that I, and any children entrusted to my care, Thriving Tots Therapy have the skills, qualifications, physical ability to properly and safely use the facilities at Thriving Tots Therapy, and Thriving Tots Therapy has not performed any type of screening to make that determination and is solely and wholly relying on my representations of those qualifications. I have read and understood the above paragraph. ___

6. Waiver – I hereby waive any protections afforded by any statute of law in jurisdiction whose purpose and/or effect is to provide that this waiver is invalid, limited or inapplicable and therefore I am releasing unknown future claims. ___

7. Representatives – I enter into this agreement for myself and child(ren) and agree to bind my heirs, assigns, and legal representatives. I have read and understand the above paragraph ___

8. If emergency First Aid is rendered, I understand that I am waiving any and all claims resulting from First Aid and all the terms and provisions of this agreement remain in full force and effect under those circumstances. I have read and understand the above paragraph I, the undersigned, am an adult entrusted to care for the child(ren) named below. I have carefully reviewed the contents of this waiver and release and knowingly and intelligently entered into this agreement, recognizing and appreciating that I am giving up mine and my child’s right to sue. I am legally authorized to sign on the child’s/children’s behalf. I desire to allow my child(ren) and/or the child(ren) entrusted to my care to use the facilities Thriving Tots Therapy. ____

This Assumption of Risk, Waiver and Release from Liability covers all activities, equipment, supplies, and Thriving Tots Therapy. I understand that any individual that is not bound by this agreement has no right to use the facilities or participate in any activities at Thriving Tots Therapy.