Waiver18 May,2018Castaway Cafe Today's Date: 01/28/2023 Waiver ID : {entry_id} In Consideration of being allowed to enter the play area and/or participate in any party and/or program at Castaway Play, Howell, MI, the undersigned, on his or her behalf, and on the behalf of the participant(s) identified below, acknowledges, appreciates and agrees to the following conditions: I represent that I am the parent or legal guardian of the participants(s) named below, or I have obtained permission from the parent/guardian of the participant(s) named below to execute this agreement on their behalf. I agree that the participant(s) named below and I shall comply with all stated and and customary terms, posted safety signs, rules, and verbal instructions as conditions for participation in any party and/or program at Castaway Play. In addition, if I observe any hazard during our participation. I will bring if to the attention of the nearest Castaway Play employee or official immediately; I am aware that there are inherent risks associated with participation in Castaway Play programs, parties, and/or use of the play area and equipment and I, on behalf of myself and the participant(s) named below, knowingly and freely assume all such risk, both known and unknown, including those that may arise out of the negligence of other participants; and I, for myself and the participant(s) named below, and our respective heirs, assigns, administrators, personal representatives, and next of kin, hereby release and hold harmless, Giles LLC, Castaway Play, LLC, and, their affiliates, officers, members, agents, employees, other participants, and sponsoring agencies from and against any and all claims, injuries, liabilities or damages arising out of or related to our participation in any and all Castaway Play programs, activities, parties, the use of the play area and/or equipment. When the Waiver Form is submitted we send you a free SMS to your phone number to deliver your Waiver ID. Msg rates may apply. By entering this facility, you are agreeing to the above terms and conditions. In addition you are also acknowledging that you and your child are free from any of the following symptoms: Nausea, Vomiting, Fever, Sore Throat, Runny Eyes, Coughing, Diarrhea, Chicken Pox, or any other illness of contagious nature. Please DO NOT ENTER if you or your child feel unwell, we will gladly give you a return visit pass if this is the case. HEALTH SCREENING COVID19:Castaway Play Café Coronavirus (COVID-19) Screening FormYou are certifying that you and the participants you have signed for have not experienced any coronavirus (Covid 19) symptoms listed below in the past 14 days Fever or chills, New loss of taste or smell, Cough, Sore throat, Shortness of breath or difficulty breathing Congestion or runny nose, Fatigue, Nausea or vomiting, Muscle or body aches, Diarrhea, Headache. You are certifying that you and the participants you have signed for have not had a positive coronavirus (Covid 19) diagnostic test in the past 14 days You are certifying that you and the participants you have signed for have not been in close contact with a confirmed/suspected coronavirus (Covid 19) case in the past 14 days If you are NOT able to certify the above questions you WILL NOT be admitted into Castaway Play Cafe. If you appear sick at time of entry you WILL NOT be admitted to Castaway Play Cafe. You and your participants agree to wear a mask the entire time you are at Castaway Play Cafe except while sitting and eating or sitting and drinking. :Please select who will be participating...* Adult Minor(s) This agreement is just for YOU. 1 Minor 2 Minors 3 Minors 4 Minors 5 Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors This agreement is for 1 MINORS.This agreement is for 2 MINORS.This agreement is for 3 MINORS.This agreement is for 4 MINORS.This agreement is for 5 MINORS.This agreement is for 6 MINORS.This agreement is for 7 MINORS.This agreement is for 8 MINORS.This agreement is for 9 MINORS.This agreement is for 10 MINORS.Participant's NameFirst minor child Participant's Name PhoneEmail Address* Enter Email Confirm Email Check to receive information, news, and discounts by e-mail. Participant's Date of Birth I certify that I am 18 years of age or older Participant's SignatureSignature*Electronic Signature Consent By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. First minor child* First PhoneMinor's Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192009/20/2016Second Minor's Full Name* 2nd Minor's Name PhoneSecond Minor's Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Third Minor's Full Name* 3rd Minor's Name PhoneThird Minor's Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Fourth Minor's Full Name* 4th Minor's Name PhoneFourth Minor's Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Fifth Minor's Full Name* 5th Minor's Name PhoneFifth Minor's Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sixth Minor's Full Name* 6th Minor's Name PhoneSixth Minor's Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Seven Minor's Full Name* 7th Minor's Name PhoneSeven Minor's Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Eighth Minor's Full Name* 8th Minor's Name PhoneEighth Minor's Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ninth Minor's Full Name* 9th Minor's Name PhoneNinth Minor's Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Tenth Minor's Full Name* 10th Minor's Name PhoneTenth Minor's Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent or Guardian's NameParent/Gardian's Full Name* Parent/Gardian PhoneParent or Guardian's Email Address* Enter Email Confirm Email Check to receive information, news, and discounts by e-mail. Parent or Guardian's SignatureSignature*Electronic Signature Consent By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. CommentsThis field is for validation purposes and should be left unchanged. Δ
