All PowerPlay Participants must complete a waiver before attending any class, camp, party or event. Save time and complete one online now. Share this page Facebook Twitter email PowerPlay Waiver Parent/Guardian Information Parent/Guardian First Name * Last Name * Email * Cell Phone Number * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Student Information Child's Name * Date of Birth * Medical Conditions if Any IEP Medical Conditions Allergies IEP Details Medical Conditions Allergies Anything else we should be aware of? Do you need to complete a waiver for a second child? Waiver Child 2? Yes No Second Child Second Child's Name * Second Child's Age * Medical Conditions for Second Child if Any IEP Medical Conditions Allergies IEP Details for Second Child Medical Conditions for Second Child Allergies for Second Child Waiver Applied to * This waiver is for (please select one)... A Birthday Party A PowerPlay Camp A Class at Powerplay After School Program (ASP) A Special Event Who's Birthday Party? Type of Camp? Which Class? How many days? Which Special Event? Assumption of Risk, Waiver of Liability, Medical Authorization I recognize that severe injuries, including permanent paralysis or death can occur in sports or activities involving height or motion, those activities including but not limited to gymnastics, tumbling, trampoline, martial arts, dance, cheerleading, ball sports, swimming and diving. In addition I recognize that swimming or any activity in or around water can result in brain damage or drowning. I am also aware that participation in day camps involves transportation to and from field trips and such transportation could cause injury or death in a vehicular accident. Being fully aware of these dangers, I hereby give consent for my children to participate in any and all Ekistics, Inc., dba Powerplay programs and activities and I ACCEPT ALL RISKS associated with this participation. I further acknowledge, understand, appreciate and agree that my participation may results in possible exposure to and illness from infectious diseases, including, but not limited to, MRSA, Influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does not exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases or others, and assume full responsibility for my participation and exposure. In consideration for my or my children's participation I hereby, for myself and my children and our respective heirs and successors, COVENANT NOT TO SUE and FOREVER RELEASE Powerplay, its officers, directors, shareholders, employees, contractors and volunteers from all liability resulting in damages or injuries incurred as a result of participation including those resulting from acts of negligence. In the event of an accident or emergency I hereby authorize my child to be transported to a hospital for medical treatment and I hold Powerplay and its' representatives harmless in the execution of such. Additionally, I hereby agree to individually provide for all medical expenses which may be incurred by myself or my children as a result of any injury sustained while participating at or for Powerplay. I have read and understand this ASSUMPTION OF RISK, WAIVER OF LIABILITY and MEDICAL AUTHORIZATION and I Voluntarily affix my name in agreement. * By signing below, I also give Powerplay permission to both take and use any photos taken for marketing publications without any compensation to me. I can opt out clearly stating so on this form. I agree to the assumption of risk, waiver, medical authorization * I agree If you'd like to receive infrequent updates and news from Powerplay, please subscribe: Checkboxes Please add me to your mailing list Sign and Submit Submitting this application and signing the waiver form, confirms that you have read and agree to all the terms outlined in our registration agreement. Your payment affirms this statement. Signature * Clear reCAPTCHA Submit If you are human, leave this field blank.