PEDIATRIC THERAPY VILLAGE (310) 953-8112

Participation Agreement, Liability Waiver , Hold Harmless Agreement

I, and as parent or legal guardian of the child (or children) whose name is set forth below (each referred to as a “Participant” and collectively referred to herein as the “Participants”) and in consideration of the Participants being permitted to participate in the Activities (as defined below) conducted by Pediatric Therapy Village, located at 14623 Hawthorne Blvd. Suite 103, Lawndale, CA 90260 agree as follows:

1. Activities – Activities shall be defined as the various activities and services offered to Participants by Pediatric Therapy Village, an indoor play gym space.

2. I understand that the employees of Pediatric Therapy Village are not responsible for Participants who utilize the space and it is the responsibility of the undersigned individual to supervise any minors they bring into the facility.

3. I, and the children under my care, understand and agree to the safety rules and play guidelines as outlined above. I acknowledge that these rules and guidelines may change and that I have read and am familiar with them prior to entering the play gym space and making use of the facility.

4. ASSUMPTION OF RISK –I understand that the Activities entail the risk of severe bodily injury to the Participants. Injuries that could result may vary, but may include (a) minor injuries such as scratches, bruises and sprains; (b) major injuries such as eye injury or loss of sight, joint or back injuries and concussions. (c) catastrophic injuries, including paralysis and even death.

5. I understand that Pediatric Therapy Village cannot eliminate all risks or guarantee the safety of the Participants while Participants participate in the Activities. I have made my own investigation of these risks, understand these risks, and assume them knowingly and willingly on behalf of myself and my minor Participant child. Notwithstanding these risks and other hazards that may be foreseeable but not specifically identified herein, I, for myself and any minor Participant child, and our respective heirs, personal representatives and assigns, understand, acknowledge, and expressly and voluntarily assume all risks and full responsibility for any injury arising out of or related to the Activities.

6. RELEASE, DISCHARGE & AGREEMENT NOT TO SUE – I, for myself and any minor Participant child and our respective heirs, personal representatives and assigns, do hereby release, discharge and agree not to sue Pediatric Therapy Village or its owners, members, employees and/or other agents, for any injury of any Participant arising, directly or indirectly, from participation in the Activities.

7. Photo Release. I grant Pediatric Therapy Village permission to use any photographs, video, or sound bites obtained of me or any minor Participant child at Pediatric Therapy’s facility for any legal use including but not limited to: publicity, advertisement and web content. I understand that no royalty or other compensation shall be payable to me or the minor Participant by reason of such use.

8. Parent or Legal Guardian Certification and Consent – I hereby certify that I am the parent or legal guardian of the minor Participant children whose name(s) appear below, and I have authority to waive rights on behalf of the minor Participant(s). I have read and I understand all of the provisions of this document and the risks of the Activities. I understand that the Activities could cause injury and even death.