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General Waiver - Location: EUPRAXIA - Chippewa Falls, WI

NAME {name} 

ADDRESS: {address}

BIRTHDATE: {dob}  

PHONE # {phone}

EMERGENCY CONTACT NAME: {contact_name}              PHONE # {contact_phone}

RELATIONSHIP: {contact_relation}

AGREEMENT/RELEASE AND WAIVER OF LIABILITY 

     I acknowledge that prior to participating in EUPRAXIA - CHIPPEWA FALLS I understand that I should consult with my physician. In attending/enrolling at EUPRAXIA - CHIPPEWA FALLS, participant understands that he/she is attending the programs and using EUPRAXIA - CHIPPEWA FALLS and the facilities at his/her own risk. 

EUPRAXIA - CHIPPEWA FALLS, INC and its Franchisee(s), owners, employees or agents, shall not be liable for any damage whatsoever arising from personal injury, including death, or property loss sustained by participant or participant’s family members in or about programs on the premises. 

   I hereby fully and forever release, discharge, hold harmless EUPRAXIA - CHIPPEWA FALLS, all associated facilities and its Franchisees, owners, employees or agents from any and all claims, demands, damages or rights of action, present or future resulting from the participation in any programs or use of the facilities. 

   I agree to follow the rules of conduct and safety set by EUPRAXIA - CHIPPEWA FALLS and its Franchisee(s), owners, employees, or agents.  Failure to do so may result in suspension from participation.

   I, the participant, do hereby grant authority to the staff at EUPRAXIA - CHIPPEWA FALLS and its Franchisee(s), owners, employees, or agents to render a judgment concerning medical assistance or hospital care in the event of an accident or illness during my absence. 

   I do herby authorization EUPRAXIA - CHIPPEWA FALLS and its Franchisee(s), owners, employees or agents and its assigns to utilize any or all photographs, pictures, videos or other likeness of me or anyone assigned guardianship to me, as they deem appropriate in its promotional materials or films. 

   I specifically waive any right to compensation for the use of such photographs, pictures videos, or others likeness.    

   I have read the above release and waiver of liability and understand its contents.  I voluntarily agree to the terms and conditions stated above.  I agree that I am legally bound by its content.

DATE: {sign_date}   SIGNATURE OF PARTICIPANT:

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