Please read and Print out.
© 2010 www.Hypermikenyc.com. Inc. All Rights Reserved
Please read this form carefully and be aware that in signing this form and participating in this
activity in instructional inline skating , you will be expressly assuming the risk and legal liability
and waiving and releasing all claims for injuries, damages or loss which you or your minor
child/ward might sustain as a result of participating in any and all activities connected and
associated with this activity.

I recognize and acknowledge that there are certain risks of physical injury to participants in this
activity, and I voluntarily agree to assume the full risk of any injuries, damages or loss,
regardless of severity, that my minor child or I may sustain as a result of participating in this
activity. I further agree to wave and relinquish all claims that I or my minor
child may have (or accrue to me or my child) as a result of participating in this activity against
the Inline skate instructor .

I do hereby fully release and forever discharge the parties from any and all claims for injuries,
damages or loss that my minor child/ward or I may have or which may accrue to me or my
minor child and arising out of, connected with, or in anyway associated with this activity.

I have read and fully understand the above important information, warning of risk, assumption
of risk and waiver and release of all claims. If allowing a minor to participate in this activity, I
further attest that I have read the above to my minor child.

Date:__________

Name PLEASE PRINT: ______________________ Signature_____________________


For Guardian or Parent, please fill out below, if Under 18 years of age.

Participant’s Name______________________

Participant’s Signature (Parent if under 18 years of age)_______________

Emergency Contact Information:   (____)______-_______

Name Phone Number (Cellphone preferable)___________________
Hypermikenyc.com inline Skate waiver