RELEASE, WAIVER OF LIABILITY, INDEMNITY, AND ASSUMPTION OF THE RISK AGREEMENT
(READ CAREFULLY BEFORE SIGNING)
IN CONSIDERATION of being permitted to participate in any way in any program, service (including but not limited to food
service), or activity offered by SMBairns Inc. d/b/a Milla’s Playland (“Company”) on or about the premises located at [7669
Limestone Drive, Suite 125 Gainesville, VA 20155] or elsewhere the (“Premises”) (collectivity, the “Activity”) at any time
EACH OF THE UNDERSIGNED, for himself/herself, his/her personal representatives, heirs, successors, next of kin, and
for the Minors (defined below) agrees (collectively, “I”, “My”, “They”, “We”, “Us” or “Our”) that:
1.
I will immediately inspect the Premises upon entering and warrant that Our entry therein and/or the participation of
the minor(s) listed below (collectively, the “Minor(s)”) in the Activity constitutes an acknowledgement that I have inspected
the Premises and find it safe and reasonably suited for the purpose of its use. I agree that if at any time in the Premises I
believe something is unsafe, I will bring it to the attention of the Company, and We will vacate the Premises and the Minor
will withdraw from participation in the Activity. I agree that either the undersigned parent and/or guardian or the designated
agent of the parent and/or guardian undersigned below (“Agent”) shall supervise the Minor at all times while on the
Premises and/or participating in the Activity. Further, the parent and/or guardian or Agent shall follow and cause the Minor
to at all times while on or about the Premises and/or participating in an Activity, follow all rules and policies of the
Company, as may be updated from time to time by the Company (“Rules”), whether the Rules are posted as safety signs
or posted as lists on the Premises, whether the Rules are communicated verbally, or whether the Rules otherwise
provided to Us. I agree that failure to follow and/or failure of the Minor to follow the Rules at all times may result in Our
expulsion from the Activity and/or Premises.
2.
I HEREBY ASSUME ALL RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE TO Us due to
negligence, gross negligence, recklessness, and intentional conduct of Releasees (defined below) or HOWEVER
OTHERWISE CAUSED, while in or upon the Premises for any purpose and/or while participating in any way in the
Activity. I recognize and understand that there are risks and dangers associated with the Minor’s and/or Our participation
in the Activity, and that admission to Premises could cause severe bodily injury, disability and death. Further, We
understand that We assume all risks in participating in the Activity and/or being admitted to the Premises, including but
not limited to the risks and dangers that may be caused by the negligent, grossly negligent, reckless, or intentional failure
to act of the (defined below) Releasees and others on or about the Premises. We assume all of the risks and dangers
associated with Minor’s participating in the Activity and/or entry into the Premises.
3.
We RELEASE, waive, discharge, hold harmless, defend and covenant not to sue the Company, its parent
companies, subsidiaries, affiliated companies, joint venturers, business partners, licensors, employees, agents,
administrators, directors, officers, members, stockholders, volunteers, customers, officials, rescue personnel, sponsors,
customers, advertisers, and/or owners as well as the lessees and licensees of the Premises (each of the forgoing shall be
considered one of the “Releasees” herein) from all liability to Us (including but not limited to the Agent), Our personal
representatives, assigns, heirs, successors, and next of kin, for any and all claims, demands, losses or damages of the
Minor and/or Us on account of any injury, including but not limited to the death or injury of Us or the Minor or damage to
property, all of which is caused or alleged to be caused by the negligence, gross negligence, recklessness, and intentional
conduct of the “Releasees” or otherwise.
4.
We hereby agree to INDEMNIFY and save and hold harmless, the Releasees and each of the Releasees from
any loss, liability, damage, cost, or fees (including but not limited to attorneys fees) that the Releasees may incur due, in
any manner or degree, to the presence of the parent/guardian or the Minor in the Premises, or related in any way to Our
participation in the Activity or presence at the Premises and whether caused by negligence, gross negligence,
recklessness, and intentional conduct of the Releasees or otherwise. We further recognize and agree We are executing
this Release, Waiver, Indemnity, and Assumption of the Risk Agreement (this “Agreement”) on behalf of Us and on behalf
of the Minor.
5.
We agree that photographs, pictures, slides, movies or videos of the Minor or of any of Us may be taken in
connection with the Minor’s or Our use of the Premises and/or participation in any Activity without compensation from the
Company or any person or entity (collectively, the “Media”) and We hereby grant to the Company a royalty-free, paid-up,
irrevocable, nonexclusive, perpetual, worldwide, license to (in any media now known or not currently known or invented)
reproduce, publish and display the Media for any purpose, including but not limited to commercial and non-commercial
purposes. We agree that the Releasees shall not be responsible for any personal property of Ours which may be lost or
stolen while We are on the Premises and further agree that no bailment with respect to any of Our personal property is
created with the Releasees.
6.
We represent and warrant that the Minor and that We are in good health and have no physical condition that
would prevent the Minor or Us from participation in the Activity. We represent and warrant that we are authorized to
execute this Agreement in the capacity listed below.
7.
This Agreement extends to all acts of negligence, gross negligence, recklessness, and intentional conduct by the
Releasees, including but not limited to rescue operations and is intended to be as broad and inclusive as is permitted by
Virginia law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in
full legal force and effect. This Agreement shall be construed in accordance with, and any and all disputes arising under or
out of this Agreement shall be governed by, the laws of the Commonwealth of Virginia without regard to principles of
conflict of laws.
ACKNOWLEDGMENT OF UNDERSTANDING: WE HAVE CAREFULLY READ, UNDERSTAND AND VOLUNTARILY
SIGN THIS AGREEMENT AND INTEND MY/OUR SIGNATURE TO BE A COMPLETE RELEASE OF ALL LIABILITY,
INCLUDING DUE TO INHERENT RISKS OR ORDINARY NEGLIGENCE BY THE COMPANY, TO THE GREATEST
EXTENT ALLOWED BY THE LAWS OF THE STATE OF VIRGINIA. FURTHER, WE ASSERT THAT WE HAVE
EXPLAINED THE RISKS OF THE ACTIVITY TO MINOR(S) AND THEY UNDERSTAND THIS AGREEMENT. WE
UNDERSTAND THAT WE ARE GIVING UP SUBSTANTIAL RIGHTS, INCLUDING OUR RIGHTS AND THE RIGHTS
OF THE MINOR(S) TO SUE FOR DAMAGES IN THE EVENT OF DEATH OR INJURY TO THE MINOR(S) OR TO US.
I CERTIFY THAT I AM AT LEAST 18 YEARS OLD AND THE PARENT OR LEGAL GUARDIAN OF THE MINOR(S) LISTED AND BY
MY SIGNATURE AGREE TO BE BOUND BY THE TERMS OF THIS AGREEMENT.
1.
Parent or Guardian (Signature and Printed Name) __________________________________________
Father / Mother / Guardian – (Circle One)
Date _____________________________
Driver’s License State and Last 5 Digits of License _______ / __ __ __ __ __
______ (Initial) I represent that I have sole legal custody or am the sole Parent/Guardian
Printed Name(s) of Minor(s):___________________________________________________________
2.
Parent or Guardian (Signature and Printed Name) __________________________________________
Father / Mother / Guardian – ;(Circle One)
Date _____________________________
Driver’s License State and Last 5 Digits of License _______ / __ __ __ __ __
______ (Initial) I represent that I have sole legal custody or am the sole Parent/Guardian
Printed Name(s) of Minor(s):___________________________________________________________
3.
Parent or Guardian (Signature and Printed Name) __________________________________________
Father / Mother / Guardian – (Circle One)
Date _____________________________
Driver’s License State and Last 5 Digits of License _______ / __ __ __ __ __
______ (Initial) I represent that I have sole legal custody or am the sole Parent/Guardian
Printed Name(s) of Minor(s):___________________________________________________________
4.
Parent or Guardian (Signature and Printed Name) __________________________________________
Father / Mother / Guardian – (Circle One)
Date _____________________________
Driver’s License State and Last 5 Digits of License _______ / __ __ __ __ __
______ (Initial) I represent that I have sole legal custody or am the sole Parent/Guardian
Printed Name(s) of Minor(s):___________________________________________________________
5.
Parent or Guardian (Signature and Printed Name) __________________________________________
Father / Mother / Guardian – (Circle One)
Date _____________________________
Driver’s License State and Last 5 Digits of License _______ / __ __ __ __ __
______ (Initial) I represent that I have sole legal custody or am the sole Parent/Guardian
Printed Name(s) of Minor(s):___________________________________________________________