For UE Staff: Entered in Mindbody?
Y
N
UE Staff Name: ____________ Date: ____________
Class Type: ______________ Amt PAID $_________ Pymt Method: _______ Entered in MB by______
www.urbanevo.com
Notes: _______________________________________________ Location: ONLINE
Parkour / Aerials / UrbanFit / Breakdancing / Group and Special Event Consent Form
Please complete BOTH sides of this form to avoid Assassination!
Participant’s Full Name: Favorite SuperHero : Parent/Guardian’s Full Name: (if participant is under 18) Home Address: Street: City: ST: Zip: Phone: Mobile: Home: E-­‐Mail Address: E-­‐mail Address: Participant’s Birth Date: (MM/DD/YYYY): How did you hear about us?: In case of Emergency (ICE) Info: Male Female Friend Referral (name)_____________________________________ Google FaceBook UE Hosted Event Meetup
YouTube Other (do tell!)________________ Birthday________________ Name: Phone: Relationship: E-­‐mail: Do you have health insurance? YES NO Pre-­‐existing Condition: Do you have any pre-­‐existing condition (injuries, recent illness, surgery or medical condition) that would limit your ability to participate?: NO YES (explain below) Current Fitness Level: What program are you interested in: Fees for intro can be credited towards monthly if you decide to sign up. (Why wouldn’t you?) Charmander(low) Charmeleon (med) Charizard (high) Parkour/Tricking and Freerunning Aerial Silks UrbanFit Breakdancing Birthday Party /Group Event Other_________________________________________________________ Training/Fitness Goals: Describe: PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK
In consideration of the services of Urban Evolution, their agents, owners, officers, volunteers, participants, employees, and all other persons or
entities acting in any capacity on their behalf (hereinafter collectively referred to as "UE"), I hereby agree to release, indemnify, and discharge UE, on
behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and
1. I acknowledge that my participation in parkour, capoeira, aerial acrobatics, break dancing, fitness training and instruction activities entails known
and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I
understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.
***PLEASE READ AND COMPLETE BOTH SIDES OF THIS FORM***
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The risks include, among other things: slips and falls; falling from equipment; rope burns; pinches, scrapes, twists and jolts that could result in
scratches, bruises, sprains, lacerations, fractures, concussions, or even more severe life threatening hazards; muscular soreness, tears, strains,
sprains, dislocations, fractures and broken bones; cuts, bruises, and muscle soreness; wrist, arm and shoulder injuries; musculoskeletal injuries
including head, neck, and back; injuries to internal organs; the negligence of other people; my own physical condition; and the risk of emotional and
psychological injuries or physical damage associated with this activity. In any event, if you or your child is injured, any medical assistance will at your
own expense.
Furthermore, UE employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant's
fitness or abilities. They might misjudge the weather or other environmental conditions. They may give incomplete warnings or instructions, and the
equipment being used might malfunction.
2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I
elect to participate in spite of the risks.
3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless UE from any and all claims, demands, or causes of
action, which are in any way connected with my participation in this activity or my use of UE’s equipment or facilities, including any such claims
which allege negligent acts or omissions of UE.
4. Should UE or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold
them harmless for all such fees and costs.
5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of
such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.
6. In the event that I file a lawsuit against UE, I agree to do so solely in the state of Virginia, and I further agree that the substantive law of that state
shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or
unenforceable, the remaining document shall remain in full force and effect.
7. I grant Urban Evolution and its designees the right to use my name, likeness, image, voice, appearance and performance whether recorded on or
transferred to videotape, film, slides, photographs, audiotapes or other media, now known or later developed. This grant includes without limitation
the right to edit, mix or duplicate, and to use or re-use recordings in whole or in part as Urban Evolution may elect. Urban Evolution or its designee
shall have complete ownership of all recordings and media in which I appear, including copyright interest, and I acknowledge that I have no interest
or ownership in the performances or their copyright. I also grant Urban Evolution and its designees the right to broadcast, exhibit, market, sell and
otherwise distribute recordings, either in whole or in parts, and either alone or with other products, for commercial or non-commercial television or
theater, closed-circuit exhibition, home video distribution or any other purpose that Urban Evolution or its designees in their sole discretion may
determine. This grant includes the right to use the Product for promoting or publicizing any of the uses. I confirm that I have the right to enter into
this Agreement, that I am not restricted by any commitments to other parties (including union memberships), and that Urban Evolution has no
financial commitment or obligations to me as a result of this Agreement. I hereby give all clearances, copyright and otherwise, for the use of my
name, likeness, image, voice, appearance and performance embodied in the Product. I expressly release and indemnify Urban Evolution and its
officers, employees, agents and designees from any and all claims known or unknown arising out of or in any way connected with the above granted
uses and representations. The rights granted Urban Evolution herein are perpetual and worldwide. In consideration of all of the above, I hereby give
my consent without requiring compensation of any sort.
Photographic, audio or video recordings may be used for: conference presentations, educational presentations or courses, informational
presentations on-line educational courses, educational videos, promotional videos, or other purposes not listed here.
By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the
Internet or in the public educational setting. There is no time limit on the validity of this release, no union relations or documents signed will apply, nor
is there any geographic limitation on where these materials may be distributed.
By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be
found by a court of law to have waived my right to maintain a lawsuit against UE on the basis of any claim from which I have released
them herein.
I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound.
Print Participant Name_______________________________________________________ Phone Number_____________________________
Address_________________________________City______________________State_____Zip________Email___________________________
Participant Signature__________________________________________________________________________ Date___________________
PARENT'S OR GUARDIAN'S ADDITIONAL INDEMNIFICATION (Must be completed for participants under the age of 18):
In consideration of ________________________________________________________________(print minor's name) ("Minor") being permitted
by UE to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless UE from any and all claims
which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.
Parent /Guardian Signature: __________________________________Print Name:________________________________ Date:____________
***PLEASE READ AND COMPLETE BOTH SIDES OF THIS FORM***
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