Read Before Signing

If participant is under 18 and parent cannot be present at
Eisenbergs at the time the waiver is signed, parent's signature must be notarized


Eisenbergs Skatepark 930 E. 15th St. Plano, TX 75074  Tel: 972.509.7725  Fax: 972.516.9807  eisenbergs.com

In consideration of being allowed to participate in any way in the Eisenbergs Skatepark program, related events and activities,

I,

PARTICIPANT INFORMATION – ALL FIELDS REQUIRED(PRINT)

Name of Participant:_______________________________________________________________

Email:______________________________ Age: _________ Date of Birth:_____________

Emergency Phone No.(s)

Home:___________________________

Cell:_____________________________

Work:____________________________

Permanent Address:_________________________________________________________________

City: _____________________ State:_________ Zip:__________


the undersigned acknowledge, appreciate, and agree that:


1. The risk of injury from inline skating, skateboarding, BMX riding, 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 KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual 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 PENAH ENTERTAINMENT CORP., d.b.a. EISENBERGS, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.


Signature If over 18 X_________________________________________________ Date Signed: _________________


Drivers License State and # __________________________________ Verified by Eisenbergs Employee ___________


FOR PARTICIPANTS OF MINORITY AGE (UNDER AGE I8 TIME OF REGISTRATION)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigned, and next of kin, I release and agree to indemnify the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.


If under 18, Parent/Guardian's Signature X________________________________________

Print Name_____________________________________________ Date____________

Parent's Drivers License State and # _____________________________ Verified by Eisenbergs Employee __________

OR

Notarized by: _______________________________ Notary Signature: __________________________ Date: __________


PLEASE TELL US HOW YOU HEARD ABOUT EISENBERGS & THEN ASK FOR YOUR FREE EISENBERGS STICKER:

FOR EISENBERGS USE ONLY -- Entered in Computer by: _________ Date Entered: _________