Berne Academy FUNDAY:) | Kidokinetics

Emergency Contact and Liability Release

Berne Academy FUNDAY:)

Fri, May 09, 2025

Berne Academy

Kid(s)

*First name

*Last name

*Dob (mm/dd/yyyy)

*T-shirt

Medical info (please list all medicines, allergies, etc)

Parent / Guardian Emergency Contact

*First name

*Last name

*Email

*Mobile phone

*Address

*City

*State

*Zip code

I agree to photo release (optional) - view

Pictures of your child participating in our fun classes may be included on the Kidokinetics.com website or other advertising materials. The child’s name will not be disclosed. Please circle below indicating whether your child’s pictures may be used by Kidokinetics. All photographs are the sole property of Kidokinetics, Inc. By checking this box, you are stating that you authorize the use of my child’s photograph by Kidokinetics to use any pictures or photographs of my child on the Kidokinetics.com website or other advertising materials, including, brochures, pamphlets, or newspaper articles. I also acknowledge that these pictures/photographs are the property of Kidokinetics. And that no royalties or payments are due in connection with their use. If you do not wish to authorize the use of my child’s photograph by Kidokinetics, please leave this box unchecked.

Parent / Guardian e-Signature

The undersigned, on his or her own behalf and on behalf of the child listed above, hereby releases Kidokinetics. from any and all liability arising out of or connected with the above-listed child’s participation in any Kidokinetics. The program, even though that liability may arise due to negligence or carelessness on the part of Kidokinetics, its officers, agents, or employees, and further, on behalf of myself and the child listed above, waive any and all claims of any kind against Kidokinetics., its officers, agents or employees arising from or in connection with the services provided by Kidokinetics as part of its programs. By agreeing, you consent to be contacted by Kidokinetics.