WaiverURLThis field is for validation purposes and should be left unchanged.Name of Parent/Guardian(Required) First Last Email(Required)Primary Phone(Required)Secondary Phone(Required)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Have you ever been enrolled at The After Glow Centre?YesNoWould You Like to Receive Information About The After Glow Centre Classes, Trials, etc.YesNoHow did you hear about The After Glow Centre?FriendsOnlineParticipants(Required)Child's NameBirthdate Add RemoveParent/Guardian SignatureAssumption of Risk Waiver of Liability-Medical Authorization-Photo Release I understand and agree to the Assumption of Risk Waiver of Liability, Medical Authorization, and Photo ReleaseRelease of Liability: Release of Liability:I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless The After-Glow Centre from any and all claims, demands, or causes of action, which are in any way connected with my participation in these activities or my use of The After-Glow Centre's equipment or facilities, including any such claims which , I, my children, parents, heirs, assigns, personal representative and estate have or may have that allege ordinary negligent acts or omissions of The After-Glow Centre. My participation in these activities is purely voluntary, and I elect to participate in these activities in spite of the risks. I have read the Assumption of Risk, Indemnity Agreement, and Release of Liability , I understand that I have given up substantial rights by signing it and have signed if freely and without any inducement or assurance of any nature and intend to be a complete and unconditional release of liability to the greatest extent allowed by law and agree that any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect.Assumption of Risk: Assumption of Risk:In consideration of participating at The After-Glow Centre, I represent that I understand the nature of this activity and that I am qualified, in good health, and in proper physical condition to participate in such activity. I acknowledge that if I believe event conditions are unsafe, I will immediately discontinue participation in activity. I fully understand that this activity involves risks of serious bodily injury, including permanent disability, paralysis and death, which may be caused by my own action, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the "releases" named below; and that there may be other risks either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a result of my participation in the activity. I hereby release, discharge, and covenant not to sue The After-Glow Centre, its respective administrators, directors, agents, officers, volunteers, employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors of premises on which the activity takes place (each are considered "releases") from all liability, claims, demands, losses, or damages, on my account caused or alleged to be caused in whole or in part by the negligence of the "releases" or otherwise, including negligent rescue operations and further agree that if, despite this waiver and release of liability, and assumption of risk, I or anyone on my behalf, makes a claim against any of the Releases, I will indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost, which any may incur as the result of a such a claim.Photo Release: Photo Release:I, give permission for my child to be photographed while doing any such activity and understand my child's photo may be displayed in various displays such as; social media, print media, and online presence. I understand no full names will be associated with these displays.
