Route 69 Roller Dome Roller Skate Permission Form

ROUTE 69 ROLLER DOME
1209 South George Nigh EXPY
McAlester OK, 74501
918-720-7042
Route 69 Roller Dome Roller Skate Permission Form
I ________________________ give my child ______________________, age _______ to roller
skate here at Route 69 Roller Dome in McAlester.
By signing this agreement I hereby give permission for my child(ren) to roller-skate at Route 69
Roller Dome. I understand that this waiver is binding contract. I also agree to the following:
1. To assume all risk and responsibilities for any injuries my child(ren) may sustain, and any
damages my child(ren) may cause to Route 69 Roller Dome., its employees, or any other
persons in conjunction with activities on the premises including anything in connection with the
equipment rented from Route 69 Roller Dome.
2. To release Route 69 Roller Dome from all claims of liability for any injuries my child(ren) may
sustain or damages that may be caused by my child(ren) or their property in connection with
their activities at Route 69 Roller Dome.
3. I will not sue, bring any claim against or bring legal action against Route 69 Roller Dome,
Route 66 Roller Dome INC., its affiliates or their respective administrators, employees,
instructors or the owners now or any time in the future.
4. That the undersigned participant(s) is in adequate physical condition to participate in the
events at Route 69 Roller Dome (Route 66 Roller Dome Inc).
5. I authorize Route 69 Roller Dome to use photographs, video, or any other record of the
events which may depict my child(ren), at their discretion, without compensation paid to me or
my child(ren).
6. I understand that any items that I (or my child) bring into Route 69 Roller Dome
(camera, MP3 player, purse, IPAD, IPOD, laptop, money, wallet, cell phone, roller
skates, other personal electronics, jewelry, etc.) are 100% my (or my childs)
responsibility. I clearly understand and agree that Route 69 Roller Dome is in no way shape or
form responsible for lost, missing, stolen or damaged items.
7. I have read the rules and regulations of Route 69 Roller Dome and I have read them to my
children. We agree to obey the rules and regulations. I fully understand that roller skating is a
dangerous sport and recreational activity. I acknowledge and completely understand that each
skater and participant will be engaging in activities that involve the risk of serious injuries,
including permanent disability, death or social or economic losses which might result from their
action, inaction or negligence. Further, there may be other risks not know or not foreseeable at
this time.
8. I am at least 18 years of age and have the legal capacity to enter into this waiver and release.
I am also the legal parent/guardian of the child(ren) attending.
Child’s signature: __________________ Date: ______ Age: ____ Date of Birth: _______
Parent or legal guardian contact information:
Parent signature (print): ___________________________ Date: __________
Parent signature: ___________________________ Date: __________
Phone: _________________________
Address:
_____________________________________________
_____________________________________________
Route 69 Roller Dome is owned and operated by
Route 66 Roller Dome INC. Copyright © 2015. All rights reserved