BRIDGE CITY ROLLER RINK

870 Center Dr       Bridge City, Texas   77611        735-4505

 

This document affects your legal rights.  You must read and understand it before signing it.

 

Last Name:______________________________________ First Name:______________________________________

 

If under 18, Age______ Birth Date ________________________   Phone:____________________________________

 

Address: __________________________________ City:______________________________  Zip:_______________

 

Parent/Guardian:_________________________________________ Driver’s License #_________________________

 

Phone #’s _______________________________________________________________________________________

 

AGREEMENT & RELEASE FROM LIABILITY

 

IN CONSIDERATION of being permitted to enter BRIDGE CITY ROLLER RINK, for any purpose, including but not limited to observation, use of facilities or equipment or participation in any way, the undersigned participant and/or legal guardian hereby acknowledges, appreciate and agree to the following:

 

1.        The risk of injury from inline skating, skateboarding, scooter play and other activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist, and

2.        I  freely assume all risks both known and unknown, even if arising from negligence of the release’s or others, and assume full responsibility for my participation: and

3.        I willing agree to comply with the stated Rules of  Safety/Code of Conduct for participation.  If however, I observe any significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately: and:

4.        I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release and hold harmless Bridge City Roller Rink, their owners, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and leasers of premises used to conduct the event (“release’s”) with respect to all injury, disability, death or loss or damage to person or property, whether arising from the negligence of the release’s or otherwise.  I have read this release of liability and assumption of risk agreement, full understand its terms, understand that I have given up substantial rights by signing it, and assign it freely and voluntarily without any inducement.

 

I HAVE READ, UNDERSTOOD AND APPROVE OF THE RELEASE FROM LIABILITY.  If the participant is a minor the undersigned parent or legal guardian warrants and represents that this RELEASE, its significance and the assumption of risk has been read to and understood by the minor child or ward.  I hereby declare, under penalty of perjury, that I am the parent or legal guardian of the name participant.

*****In the event of sudden illness, accident, or injury which may occur while my child or ward, above identified, is engaged in an activity supervised or sponsored by BRIDGE CITY ROLLER RINK directors, employees, agents or volunteers, and a parent or guardian can not be contacted, I hereby give my consent for emergency medical treatment as shall be necessary under the circumstances by any medical provider licensed under the laws of the State of Texas.

 

Participant: __________________________________________________________________________ Date: ________________________

 

Parent/Guardian of Minor: _____________________________________________________________ Date: ________________________

 

SIGNATURES MUST BE WITNESSED BY BCRR EMPLOYEE OR NOTORIZED ….. NO EXCEPTIONS

 

ACKNOWLEDGEMENT

State of Texas                                                                                                                                                       County of  __________________

 

                On __________________________ before me, _________________________________________ personally appeared________________________, ( )personally known to me – OR – ( ) proved to me on the basis of satisfactory evidence to be the person (s) whose name (s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity (ies), for the purposes and consideration therein expresses.

 

 

WITNESS my hand and official seal.      ______________________________________________________ Signature of Notary