Libero Virginia

PHOTO RELEASE, ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM

44670 Cape Court Unit 120, Ashburn, VA 571-225-8210 liberovirginia.com/

FAMILY INFO

Parent/Guardian/Participant (if over 18)

First Name *

Last Name *

BirthDate *

E-mail *

Main Contact (Phone Number) *

Street Adress *

City *

State *

Zip Code *

How did you hear about us?
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MEMBERSHIP AGREEMENT AND OF RISK AND WAIVER LIABILITY

As a legal parent or guardian of the names listed on this registration form, I hereby consent to the mentioned below person(s) including the parents and legal guardians listed will be participating in Libero LLC programs, including but not limited to volleyball, fitness, gymnastics, danceand related activities including bouncing, tumbling and trampoline. I recognize that potential severe injuries or death may occur in any activity developed during Libero LLC programs. If I and/or any other Participant at Libero LLC programs are injured, I acknowledge that we may require medical assistance, which I acknowledge will be at my own expense or expense of my personal insurer(s). I hereby represent and affirm that I have adequate and appropriate insurance to provide coverage for such medical expense, or else I agree to bear the cost myself. I understand and agree that Libero LLC will not pay any cost or expenses incurred by me if I and other participant becomes injured.
I hereby grant Libero LLC the right , without reservation or limitation, the unrestricted right and copyright to photograph, videotape, and/or record me and each participant and to use my and each participant’s name, face, likeness, voice and appearance in connection with publicity, advertising and all other promotional materials of any nature and kind. On behalf of myself and each other participant, I hereby further expressly release and waive any demand, action, claim, license and any right to any form of payment that I and each other participant may have arising out of relating to any use of our name, face, likeness, voice and/or appearance.
The acknowledgement MEMBERSHIP AGREEMENT AND OF RISK AND WAIVER LIABILITY, having been read thoroughly and understood completely, is signed voluntarily as is its content and intent.

* I have read and
understand the above:

* My signature indicates my (our) agreement with the Parental Release