Roller Dome Stillwater Roller Skate Permission Form

ROLLER DOME STILLWATER
1519 N. Cimarron Plaza
Stillwater, OK 74075
1-844-765-5373
Roller Dome Stillwater Roller Skate Permission Form
I ________________________ give my child ______________________, age _______ to roller
skate at Roller Dome Stillwater.
By signing this agreement I hereby give permission for my child(ren) to roller-skate at Roller Dome
Stillwater. I understand that this waiver is binding contract. I also agree to the following:
1. To assume all risk and responsibilities for any injuries my child(ren) may sustain, and any
damages my child(ren) may cause to Roller Dome Stillwater, its employees, or any other persons
in conjunction with activities on the premises including anything in connection with the
equipment rented from Roller Dome Stillwater.
2. To release Roller Dome Stillwater from all claims of liability for any injuries my child(ren) may
sustain or damages that may be caused by my child(ren) or their property in connection with
their activities at Roller Dome Stillwater.
3. I will not sue, bring any claim against or bring legal action against Roller Dome Stillwater,
Roller Dome Stillwater INC., its affiliates or their respective administrators, employees,
instructors or the owners now or any time in the future.
4. That the undersigned participant(s) is in adequate physical condition to participate in the
events at Roller Dome Stillwater (Roller Dome Stillwater Inc.)
5. I authorize Roller Dome Stillwater to use photographs, video, or any other record of the
events which may depict my child(ren), at their discretion, without compensation paid to me or
my child(ren).
6. I understand that any items that I (or my child) bring into Roller Dome Stillwater
(camera, MP3 player, purse, IPAD, IPOD, laptop, money, wallet, cell phone, roller
skates, other personal electronics, jewelry, etc.) are 100% my (or my child’s)
responsibility. I clearly understand and agree that Roller Dome Stillwater is in no way shape or
form responsible for lost, missing, stolen or damaged items.
7. I have read the rules and regulations of Roller Dome Stillwater and I have read them to my
children. We agree to obey the rules and regulations. I fully understand that roller-skating is a
dangerous sport and recreational activity. I acknowledge and completely understand that each
skater and participant will be engaging in activities that involve the risk of serious injuries,
including permanent disability, death or social or economic losses which might result from their
action, inaction or negligence. Further, there may be other risks not know or not foreseeable at
this time.
8. I am at least 18 years of age and have the legal capacity to enter into this waiver and release.
I am also the legal parent/guardian of the child(ren) attending.
Child’s signature: __________________ Date: ______ Age: ____ Date of Birth: _______
Parent or legal guardian contact information:
Parent signature (print): ___________________________ Date: __________
Parent signature: ___________________________ Date: __________
Phone: _________________________
Address:
_____________________________________________
_____________________________________________
Roller Dome Stillwater is owned and operated by
Route 66 Roller Dome INC. Copyright © 2016. All rights reserved