Ben & Claire LLC, dba Kids Ground

Accident Waiver and Release Liability Form

(on behalf of a minor child/ren)

  I certify, I am the adult parent/guardian of a minor child/(ren) under the age of 18. I consent to the participation in the activities and use of the space of Kids Ground (“the facility”) located at 8010 Gramercy Blvd, Suite B, Rockville, MD 20855. By signing this form, I acknowledge this Accident Waiver and Release of Liability of Liability Form as an agreement that will be used by Kids Ground, and it will hold me accountable for my actions and responsibilities, and of the child(ren).

  The participation at Kids Ground, and all its activities offered may tests one’s physical, mental limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are not limited to, event caused by the terrain, facility, temperature, weather, the condition of person(s), equipment, dehydration, and actions of others, but not limited to participants, monitors, and the producers of the activity. I hereby assume all of the risks of participating in any and all activities associated with the facility, and not limited to any risks that may arise from negligence, carelessness on part of the person(s) or entities and including any use of equipment that is dangerous and/or defective that is owned and/or maintained.

  By signing this waiver, I hereby waive, release and forever discharge from liability, Ben & Claire LLC, dba Kids Ground and their respective agents, employees, officers, directors, shareholders, and any other person associated with the facility from all claims and actions of any kind and nature which are related in any way, indirectly or directly, from the use of Facility or participation in any activity that was offered in any part of negligence. I understand that I will be responsible for all risks associated with the minor(s) participating and that I am here with the minor(s) at my own risk and expense and agree I will not bring any claim or cause of any action of any kind or nature against Ben & Claire LLC, dba Kids Ground and any respective agents, employees, officers, directors or any person associated with the entity. I further agree to indemnify, defend and hold harmless Ben & Claire LLC, dba Kids Ground, and any person associated with the facility from any claims are causes of action from the use of the facility.

  By accepting below, I acknowledge and agree I have read this Waiver/Agreement and understood all the terms and conditions and that this Waiver/Agreement will be in full force and effect at all times being present at the Facility and/or participating in any services offered by or through the Facility. By signing below, I am aware that this is a release of liability on behalf of myself and a minor child/(ren), and I accept the terms of this waiver of my own free will.

Photography, Video and Picture Release

(on behalf of a minor child/ren)

  By accepting this waiver, I grant Ben & Claire LLC, dba Kids Ground the permission to record on photography film, video, and pictures of participation by you and the minor child/(ren). All materials that is photographed may be used in future publication, brochures, or printed materials and social media that will be used to promote and advertise Ben & Claire LLC, and as such there will no payment, fees, royalties, discounts or any form of repayment given by the facility in any kind.

Parent / Guardian Information

Name

Email & Phone

Minor Information

Parent / Guardian's Signature

Electronic Signature Consent


COVID Warning & Health Log

(on behalf of a minor child/ren)

  We, Ben & Claire LLC, dba Kids Ground have taken enhanced health and safety measures within the facility. We ask all our customers to wear facemasks the whole time they are present at Kids Ground. There is a risk of exposure to COVID-19 in public places where people are present. By visiting Kids Ground, you voluntarily assume all risks associated with COVID-19 and we, Ben & Claire LLC, dba Kids Ground will not take any responsibility. We ask we keep each other healthy by not visiting Kids Ground if you, the adult/guardian and/or child have any of the symptoms below:

  1. Temperature of 100 degrees Fahrenheit or higher
  2. Couth
  3. Runny nose
  4. CouthShortness of breath or difficulty breathing
  5. Chills
  6. Muscle pain
  7. Headache
  8. Sore throat
  9. Loss of taste or smell
  10. Diarrhea

  Upon arrival, if the adult/guardian and/or child have a fever of 100.4 Fahrenheit, we will ask you to leave and come back at a later date.


  Below is a health log we will ask you to fill out every time you arrive to Kids Ground. While you do not need to fill out the whole waiver again, we will ask you to fill out a health log before your arrival. We thank you in advance.


a. Has your child had any symptoms (e.g., sore throat, nasal congestion, runny nose, new or worsening cough, shortness of breath, fatigue/malaise, headaches, body aches, nausea, vomiting, diarrhea, loss of taste or smell) since yesterday? Or in past 14 days if new or returning from absence?
b. Has your child been given a fever reduced in the last 24 hours?
c. Are there any family members in your household with symptoms consistent with COVID-19?
d. Has your child had close, prolonged contact with anyone known to have COVID-19 or who has symptoms of COVID-19 (e.g., fever, sore throat, nasal congestion, runny nose, cough, headaches, body aches, fatigue/malaise, nausea, vomiting, diarrhea, loss of taste or smell) since yesterday? Or in past 14 days if new or returning from absence?