Waiver/Release Form

Due to the nature of skateboarding, it is understood that I release Suburban Blend, its members, sponsors, agents,
event site, employees, leadership, or any official that is connected with this skateboard demonstration, from all liability of any sort, and that they may be held harmless and indemnified for any other accident or injuries sustained by me/my child while participating in the skateboard demonstration.

Participant, parent and or legal guardian acknowledge and fully understand that skateboarding is an activity/sport that can involve certain risk and serious injuries. Some are: permanent disabilities and death, severe social and economic losses might result not only from my own actions, inaction or neglect, but the actions, inaction, or neglect of others, the rules of play or condition of the premises or of any equipment being used. Further there may be other risks not known to me or not foreseeable at the time.

I understand, consent, to and authorize, in advance, the use of my name, voice, picture, or other likeness, in
combination or alone, in any broadcast, telecast, print medium, advertising, promotion, or any other account of the
skateboarding event. I represent that my minor child or I are in sufficiently good physical condition to participate in
the programs and activities of the skateboard demonstration without jeopardizing our health, I understand that I have
given up substantial rights by signing this waiver and release, and sign it voluntarily. This waiver also binds my heirs and assignees.

Authorization to treat a minor and/or release patient’s records: 1) I, we the undersigned, do herby authorize any
hospital, physician, or other person who has attend me or examined me to furnish Suburban Blend, or its
representatives, any and all information with respect to illness, injury, medical history, consultation, prescriptions, or
treatment, and copy all hospital or medical records. A photo static copy of this authorization shall be considered as
effective and valid as original. 2) I, we the parent/s or legal guardian of the below named minor, do authorize the
consent to any x-ray examination, laboratory procedure, anesthetic, medical, or surgical diagnosis and treatment which is deemed advisable by general medical staff or emergency room under the provisions of the state of  New York, Department of Public Safety. 3) I, we understand that every effort shall be made to contact me/us prior to rendering treatment to the patient, but that any of the above treatment will NOT be withheld if I, we cannot be reached. 4) It is understood that the persons presenting this authorization is acting as my/our agent and will not be held liable for treatment/s and other services rendered. 5) I, we accept full financial responsibility for all medical treatment.

Participant Information:
First name: ___________________________ Last name: ___________________________
Address: __________________________________________________________________
City: ____________________________ State: ___________ Zip: ____________________
Home Phone: ______________________________________ Age: ___________________
Emergency Contact:
First name: ___________________________ Last name: ____________________________
Phone: ___________________________________________ Relation: _________________
Participant Signature: ___________________________
Parent/s or legal guardian Signature: ___________________________
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