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Kids Playing with Lego



I hereby consent and agree that Tiffani Rosenbleeth and VILLAGE SQUARE, LLC have the right to take and/or use photographs and/or video of my child and/or me to use in all media and print, including online. I hereby release the photographer all rights to exhibit this work in print and/or electronic form publicly and/or privately and to market copies. I release and waive any claims or rights of compensation or ownership regarding such uses and understand that all such recordings shall be property of VILLAGE SQUARE, LLC. I am at least 18 years of age. I have read and understand the foregoing statement and I’m confident in executing this agreement.


Your Name ______________________________________________

Phone Number ___________________________________________

Email ___________________________________________________

Your Child’s Name ________________________________________

Host’s Name _____________________________________________

Date of Party _____________________________________________

I consent ___________  I do not consent __________

*If you DO NOT consent, please identify your child by what he or she is wearing. Thank you.


Does your child have any known food allergies? ___________________________


I understand the inherent risk of injury or illness does exist. I, and the children, have no illness or injury that may affect the safe enjoyment of VILLAGE SQUARE, LLC by other guests. I knowingly and freely assume full responsibility for myself and the children accompanying me to VILLAGE SQUARE, LLC. I freely assume all risks, both known and unknown even if arising or resulting from the acts or omissions of VILLAGE SQUARE, LLC, its staff or its customers. I, for myself, my child/ren, or ward/wards, and on behalf of my or their heirs, assigns, personal representatives and next of Kin, hereby hold harmless VILLAGE SQUARE, LLC, its owners, members, employees, equipment manufacturers, landlord and sponsoring agencies from all and any liability for any personal injury, disability, death or lose of damage to person or property to the fullest extent of the law. I understand that my execution of this waiver will authorize VILLAGE SQUARE, LLC to enter this waiver into its database and use it as a continuous, multi-use waiver for my child(ren)'s on-going participation in any and all activities held at VILLAGE SQUARE, LLC. I, the child(ren)'s parent and/or legal guardian, represent that I understand the nature of the activities and that I, and the above-named child(ren) are qualified, in good health, and in proper physical condition to participate in such activities. I acknowledge that if I believe any conditions are unsafe, I will immediately discontinue participation in such activities. I fully understand that the activities involve risks of serious bodily injury, including permanent disability, paralysis and death, which may be caused by my own or the above-named child(ren)'s actions, inactions, those of others playing while we are here, the conditions in which the event takes place, or VILLAGE SQUARE, LLC or its staff; 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 and such risks and all responsibility for losses, cost, and damages I or the above named children(ren) incur as a result of my or the able named child(ren)'s participation in the activities. I hereby release, discharge, hold harmless, and covenant to sue VILLAGE SQUARE, LLC for any injuries that may occur or its administrators, directors, managers, members, volunteers, and employees from any and all liability claims, demands, losses, or damages, on my account or the child(ren)'s account caused or alleged to be caused in whole or in part by the acts or omissions of VILLAGE SQUARE, LLC administrators, shareholders, directors, agents, officers, managers, members, volunteers,  and employees.

I have read and understand the foregoing statements and I am competent to execute.

Signature: ____________________________   

Date of Contract: ___________________________________

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