D.K.'s Mainstreet Skate Park
CALL FOR INFO. ON OUR PRIVATE SESSIONS & LESSONS FOR SKATE & BMX

Waiver of Liability

Print out this waiver, fill it out completely and send it to us with $5.00 and we will mail you a D.K.'s membership card and free stickers.
THIS WAIVER WILL ONLY BE KEPT ON FILE 1 DAY UNLESS CARD PURCHASED
Name:________________________________
Age:____________ D.O.B.:_______________
Address:_______________________________________
Parent's Name / Names:___________________________
Home Phone:____________ Work Phone:_____________
Doctor's Name:__________________________________
Doctor's Phone:__________________________________
Insurance Provider and Number:[OR WRITE :WILL SELF PAY]____________________


AGREEMENT:

I hereby agree that in consideration of the opportunity to participate and recognizing that such an understanding involves an element of risk, I assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify, and agree to hold harmless Cindy Ayers, Dan Ayers, D.K.'s Mainstreet Skatepark, it's agents, employees, and officers, from liability, for injury, illness, or death incurred as a direct or indirect result of this activity.
We the undersigned have read this release and understand all it's terms and execute it voluntarily, and with knowledge of it's significance.

______________           ____________________________
Date                                                Signature             

In case of emergency or illness, please contact:
1)_____________________________________________
      Name, Address, & Phone number
2)_____________________________________________
      Name, Address, & Phone number

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   Under Age form for people less than 18 years of age.
Name of Minor(s): ____________________________________

 ANY ADULTS THAT WILL BE IN RAMPS AREA -SIGN HERE ________________________

After reading and fully understanding the forgoing agreement, I, _________________, (Father / Mother / Guardian) of the above named minor, allow him/her to participate actively in skating activities at D.K.'s Mainstreet Skate Park and agree to provisions contained in the above agreement. I sign as my own free act.

___________      _______________________________
Date                      Signature of Father / Mother / Guardian   


* Any special circumstances regarding my child:_____________________________

Parent or Guardian or person 18 years or older, please place ID Here
Copy this form on a photocopy machine and then fill in the form.
 

Private sessions available early and late most any day! Skateboards, bikes, and inline..Call or email for details. CALL THIS CELL NUMBER, IF NO ANSWER AT SHOP - 765/434-5539
1016 S. Main Street · Kokomo, IN 46902 · Phone (765) 868-8090 · Email: EYESK8@HOTMAIL.COM