Pirate Play Open House Event Waiver

First Name *

Last Name *

Phone *

Email *

Child(ren)’s Name(s) and Age(s) *

Assumption of Risk

Participation in the Pirate Play Open House, including use of the pirate ship play structure, involves physical activity and inherent risks such as slips, falls, or collisions. By agreeing below, you acknowledge and accept these risks on behalf of your child(ren). *

I understand and agree

Release of Liability

By allowing your child(ren) to participate, you agree to release and hold harmless Power Within Child Therapists, its owners, employees, contractors, volunteers, affiliates, landlords, and event partners from any claims or liability related to participation in this event, to the fullest extent permitted by law. *

I agree to the release of liability

Medical Authorization

In the event of an emergency, you authorize Power Within Child Therapists and/or event staff to seek medical treatment for your child if you cannot be reached. You understand that you are financially responsible for any medical care provided. *

I authorize emergency medical treatment if necessary

Supervision Agreement

Parents and guardians are responsible for supervising their child(ren) at all times during the event. Power Within Child Therapists and event staff do not provide child supervision. (copy) *

I understand and agree

Photo & Media Release

During the event, photos or videos may be taken to capture the fun and community atmosphere. These images may be used by Power Within Child Therapists for marketing, educational, or promotional purposes (such as on our website, social media, or printed materials). Your child’s name will never be used. *

I understand and agree

By checking this box, You agree to receive informational messages (appointment reminders, account notifications, etc.) from Power Within Child Therapists. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at [email protected]. You can opt out at any time by replying STOP.

See Privacy Policy & Terms and Conditions for more.

By signing below, you are confirming that you are the legal parent or guardian of the child(ren) listed and that all information provided is accurate.

Signature & Acknowledgment

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