Create Waiver Please enable JavaScript in your browser to complete this form.Select Your Location *BountifulSandySouth OgdenChild's Name *FirstLastParent's Name *FirstLastPhone *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParticipationThe undersigned(s) being lawful parent(s) and/or guardian(s) of the above-named Child, hereby consent to the participation by the Child in teaching the activities, curriculum, and programs (the “Program”) conducted by ECLIPSE LEARNING CORP. d/b/a CODE NINJAS, and it’s directors, officers, employees, agents, and authorized personnel (collectively, the “Provider”), and to the participation of the Child in all events related to said Program. I. Services ProvidedIn Exchange for the payment(s), assumptions of risk, releases of liability, and/or waivers of liability described below. Provider agrees to provide the Create Program to Child, in accordance with the dates and times evidenced therewith. Provider reserves the right to dismiss any child or student that acts with conduct in violation of the Program and Provider’s direction and rules of conduct. Grounds for dismissal shall be for reasonable cause, as determined in the sole discretion of Provider, and such dismissal shall not relieve Parent of any duties or payment obligations thereafter or entitle Parent to any refund. Furthermore, the Program requires active participation of Child in accordance with the Program’s curriculum. PROVIDER DOES NOT WARRANT ANY SPECIFIED SUCCESS RATE RESPECT TO PARTICIPATION IN THE PROGRAM OF CHILD. THE PROGRAM IS NOT CONSIDERED A CHILD CARE PROGRAM, CHILD CARE CENTER, HOURLY CENTER, OR AN OUT-OF-SCHOOL PROGRAM, AND IS NOT LICENSED WITH THE STATE OF UTAH FOR THOSE PURPOSES. II. Payment of ServicesPayment for the Create Program shall be payable monthly. The monthly price is $200, with the first monthly payment due immediately upon execution of this agreement and the remainder months payable on the same day the following month that is not a legal U.S. holiday (“Due Date”). After the Initial Term, this agreement automatically renews on a month to month basis at a price of $200, unless terminated by Parent by providing sixty (60) days written notices to Provider at the Provider’s location. I/Parent acknowledge that any payment made five (5) or more days past its Due Date is considered past due. An interest rate of 1.5% per month shall be charged by Provider on all fees or payments past due. I/Parent shall be responsible for payment of all costs and reasonable attorney fees incurred by Provider as a result of collection, including those costs and fees incurred as a result of litigation and/or arbitration proceedings. I further acknowledge that any late payment shall constitute grounds for immediate dismissal of Child from the Program and shall not relieve me of any liability for past due amounts and/or future payment obligations.III. Emergency Medical TreatmentIn the event of a medical emergency, the Program staff will first use reasonable efforts to contact parent(s) and/or guardian(s) before administering or authorizing any treatment. However, I/Parent understand that Provider does not have medical personnel available at the Facility. I/Parent agree and hereby grant Provider permission to authorize emergency medical treatment, if necessary, to Child. I/Parent understand and agree that Provider assumes no responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment. I/Parent further state that there are no undisclosed health-related reasons or problems which preclude or restrict my Child from use of the Program, and that my Child has adequate health insurance to provide for and pay any medical costs that may be attendant as a result of injury to Child. I/Parent further acknowledge that it is my sole responsibility to notify, inform, and update Provider of any medical conditions of Child, including but not limited to known drug and food allergies, known dietary restrictions, and other medical conditions. Initial *I hereby acknowledge and affirmatively represent that my Child does NOT have any food or drug allergies, or any dietary restrictions, other than those provided to Provider in writing in conjunction with this agreement. IV. Cell Phone PolicyI/Parent understand that the use of personal cell phones in the dojo is strictly prohibited. Not only can it interfere with the work of clients and be disruptive to others, but Provider carefully guards its intellectual property and propriety information. I/Parent understand that if my child brings a personal cell phone they are required to keep the ringer shut off or placed on vibrate mode when they are in the dojo, put the cell phone in a pocket or bag, and not remove the cell phone while in the dojo.Medial Consent and Release for Minor ChildrenI, as the parent or guardian of Child, hereby grant Provider permission to use photographic portraits, pictures, digital images, or videos of Child, or in which Child may be included in whole or part, or reproductions thereof, for any lawful purpose, including but not limited to use in any Provider publication or on Provider websites, including social media, without payment or any other consideration. I hereby waive any right that I may have to inspect and/or approve the finished product or copy that may be used in connection therewith, wherein Child’s likeness appears, or the use to which it may be applied. I hereby release, discharge, and agree to indemnify and hold harmless the Provider and it agents from all claims, demands, and causes of action that I or Child have or may have by reason of this authorization or use of Child’s photographic portraits, pictures, digital images or video, including any liability by virtue of any blurring, distortion, alteration, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videos, or in processing tending towards the completion of the finished product, including publication on the internet, in brochures, or any other advertisements or promotional materials. Please check on of the boxes below and insert your initials to signify your consent or non-consent to the above policy. Initial – CONSENTI hereby acknowledge and affirmatively represent that I am the parent and/or guardian of Child and do hereby give my consent without reservation to the foregoing Media Consent and Release for Minor Children on behalf of my Child.Initial – NON-CONSENTI hereby acknowledge and affirmatively represent that I am the parent and/or guardian of Child and do not hereby give my consent without reservation to the foregoing Medial Consent and Release for Minor Children on behalf of my Child.VII. Release of LiabilityTHIS IS A RELEASE OF LEGAL RIGHTS. READ AND BE CERTAIN YOU UNDERSTAND BEFORE SIGNINGInitial *I/PARENT DO HEREBY IN ADVANCE WAIVE, RELEASE, ACQUIT, FOREVER DISCHARGE, AND COVENANT NOT TO SUE PROVIDER, ITS OWNERS, AGENTS, EMPLOYEES, AND ALL PERSONS AND ENTITIES OF, FROM ANY/ALL ACTIONS, CAUSES OF ACTION, CLAIMS, DEMANDS, DAMAGES, COSTS, LOSS OF SERVICES, EXPENSES, AND COMPENSATION, ON ACCOUNT OF OR IN ANY WAY GROWING OUT OF, ANY AND ALL KNOWN OR UNKNOWN PERSONAL INJURIES, PERSONAL PROPERTY DAMAGE, OR DEATH RESULTING FROM MY CHILD’S ATTENDANCE OF THE PROGRAM. SHOULD I OR MY SUCCESSORS ASSERT MY CLAIM IN CONTRAVENTION TO THIS AGREEMENT, I AND MY SUCCESSORS SHALL BE LIABLE FOR THE EXPENSES INCLUDING LEGAL FEES INCURRED BY THE OTHER PARTY OR PARTIES IN DEFENDING UNLESS THE PARTY OR PARTIES ARE ADJUDICATED FINALLY LIABLE ON SUCH CLAIM FOR WILLFUL AND WANTON NEGLIGENCE. THIS AGREEMENT CONTAINS THE ENTIRE AGREEMENT BETWEEN THE PARTIES, AND THE TERMS OF THIS RELEASE ARE CONTRACTUAL AND NOT A MERE RECITAL. THIS RELEASE EXTENDS TO AND INCLUDES, BUT IS NOT LIMITED TO, ALL DAMAGES OF EVERY KIND, COMPENSATORY, STATUTORY, CONTRACTUAL, AND UNDER WARRANTY, ALLEGEDLY OCCURING BOTH IN THE PAST AND WHICH ALLEDGEDLY MAY OCCUR IN THE FUTURE, WHICH COULD BE ASSERTED BY ME (PARENT), CHILD, OR BY OTHERS CLAIMING DAMAGES FROM ANY INJURIES I OR MY CHILD MAY SUSTAIN AS A RESULT OF MY EXECUTION OF THIS AGREEMENT OF CHILD’S PARTICIPATION IN THE PROGRAM; INCLUDING ALL PREJUDGEMENT AND POST-JUDGEMENT INTEREST; AND ANY AND ALL OTHER ALLEGED DAMAGES, ALL LOSSES AND EXPENSES OF EVERY KIND, WHETHER KNOWN OR UNKNOWN, AND WHICH ARE OR MAY BE ATTRIBUTABLE TO PROVIDER OR PROVIDER’S EMPLOYEES, OFFICERS, OR AGENTS, ALL OF WHICH ARE RELEASED HEREIN.Signature *Clear SignatureDate *Submit