SKATEPARK WAIVER AND RELEASE FORM

(Read Before Signing)

In consideration of being allowed to participate in any way, in any Title 10 Corp. facility, or related events or activities,

I ________________________________________, (Print Participant’s Full Name) the undersigned acknowledges, appreciates and agree that:

1. The risk of injury from the activity in this program is significant, including the potential of permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce the risk, the risk of serious injury does exist: and,

2. I KNOWLINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation: and,

3. I willingly agree to comply with the state and customary terms and conditions for participation, and the “Rules and Regulations” set forth by Title 10 Corp... If however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such a hazard to the attention of the nearest staff member immediately: and,

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS, Title 10 Corp., its directors, officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable owners and lessors of the premises used to conduct the event (“Releasees”). WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, OR LOSS OR DAMAGE TO PERSON OR PROPERTY, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.

5. I hereby give permission for pictures of myself to be taken and potentially used for news reporting and/or the promotion of Title 10 Corp. These pictures may be used in print form or on the website. As well, I agree that at any time I no longer wish to receive email correspondences from Title 10 Corp., I will notify the Director of Operations via email or letter and will be removed within 72 hours of the receipt of the notification.

I have read this release of liability and assumption of risk agreement.  I fully understand its terms, understand that I have given up substantial rights by signing it and sign it freely and voluntarily without any inducement.

___________________________ AGE: ________ Date Signed: _____________

    ^{(Participant’s Signature)}              DATE OF BIRTH: _______________

Street Address: ____________________________________________________

City: ___________________________   State: _______   Zip: _______________

Phone Number: ___________________ Email: ___________________________

Emergency Contact Name: _________________Relationship:_______________

Emergency Contact Phone Number: ___________________________________

FOR PARTICIPANT’S UNDER THE AGE OF 18 AT THE TIME OF REGISTRATION

This is to certify that I, as the participant’s parent/legal guardian, do consent and agree to his/her release as provided above of all Releasees from any and all liabilities incident to my minor child’s involvement of participation in the programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.

_____________________                  _________________________          ____________

Parent/Guardian Signature                     Parent/Guardian Printed Name  Date Signed

Check appropriate capacity:                         Parent ______             Guardian ______

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If not signed in the presence of a Title 10 Skatepark employee, your signature must be notarized.

Notary Public

STATE OF ________________

                                                            :ss.

COUNTY OF _____________

            On this, the _____ day of _________________ 20____, before me, a Notary of Public in and for the Commonwealth / State (Circle One) of ________________ personally appeared _______________, who acknowledged himself/herself to be the ______________ of _____________________, a minor, and that he or she, in such capacity, is authorized to execute the foregoing instrument on behalf of the child for the purposes therein contained.

            IN WITNESS WHEREOF, I hereunto set my hand and official seal.

                                                                                    _______________________________

                                                                                    Notary Public

                                                                                    My Commission Expires

Revised 1/20/04