Lazerland of LI
54A Motor Parkway
Commack, NY 11725


1. Name(s) of Participant(s):


2. Parent or Legal Guardian:

Name: ____________________________________________________________

3. I (the “Signatory”) represent that I am a parent or legal guardian of the participant(s) listed above or that I have obtained the permission from a parent or guardian of each such participant(s) with respect to whom I am not a parent or legal guardian for such participant(s) to participate in one or more of the following (please check the one(s) you presently contemplate the participant(s) will participate in):

___ Laser Tag ___ Dodgeball ___ Bouncey Fun Express Train Station ___Jr. Sports Activities

at Lazerland of LI at 54A Motor Parkway, Commack, NY 11725.

4. I, for myself and on behalf of the above-referenced participants, and parents and legal guardians (if any):
A. Acknowledge that participation in the activities selected above involves physical activity and/or the use of equipment apparatus and facilities that could result in injury to the participant; assume full responsibility for any injuries or damages which may occur to, or be caused by, each above-referenced participant in, on or about Lazerland of LI’s premises or as a result of participation in any of the activities at Lazerland of LI, from whatever cause, including, without limitation, the negligence of Lazerland of LI, its owners, employees, agents, customers, invitees or visitors; and release, discharge, and agree to indemnify and hold harmless (jointly and severally if there is more than one above–referenced participant and more than one above-referenced parent or legal guardian) Lazerland of LI, its owners, employees, and agents from and against all loss, liability and expense, present or future, whether or not known or anticipated, arising out of or resulting from, directly or indirectly, my or any above-referenced participant’s presence at Lazerland of LI’s premises, use or intended use of or participation in any of the games featured, offered or conducted at Lazerland of LI, use or intended use of Lazerland of LI’s premises or facilities and/or use or intended use or any equipment or apparatus related thereto. The undersigned has read and understands the foregoing waiver. The undersigned acknowledges that he/she has discussed the terms and conditions of this waiver with a parent or legal guardian of each above-referenced participant and has received each such parent’s/legal guardian’s consent to the provisions, agreements, terms and conditions of this waiver.

B. Agree to cause each above-referenced participant to participate in the activities at Lazerland of LI according to the rules and instructions given to me or to any such participant by any members of Lazerland of LI’s staff; and acknowledge that Lazerland of LI accepts no responsibility for any act or anything done by me or any such participant which is not in accordance with the rules and instructions of Lazerland of LI.

C. Accept full responsibility for any damage to the Lazerland of LI premises, facilities, and/or equipment caused by me or by any of the above-referenced participants.

D. Agree to inform a member of Lazerland of LI staff of any medical condition or treatment that I have, or that any above-referenced participant has, prior to the participation by myself or by any such participant in any activity at Lazerland of LI.

E. The participant (s) are 6 years of age or older.

Signature of the Signatory: _________________________________ Date Signed:______________


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OFFICE USE ONLY Membership #____________________________

Membership Expires_______________________

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