PLEASE READ ALL SECTIONS CAREFULLY! THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS.

The individual named below (referred to herein as the “Individual”) desires to participate in activities and events (the “Activities”) provided by Little Pinecones Play Cafe, a Virginia limited liability company (the “Company”), and use the facilities of the Company located at located at TBD, (the “Property”). In consideration of being permitted by the Company to participate in the Activities and enter the Property, and in recognition of the Company’s reliance hereon, the Individual, and the Individual’s parent or legal guardian (if the Individual is a minor), does hereby agree to all the terms and conditions set forth in this instrument (this “Release”).

1. I attest that I am the parent or legal guardian of the minor participant(s) named herein below, or that I have obtained permission from the parent/legal guardian of the participant(s) to execute this agreement on their behalf and agree to attend to and monitor the activities of all participant(s) such that all activities are age and ability appropriate;

2. I agree that the participant(s) and I shall willingly comply with all stated and customary terms, posted safety signs, rules, and safety instructions and directions by Little Pinecones Play Cafe, LLC and its staff as conditions for use of play equipment and participation in any event, activity, program, or party. In addition, if I observe any hazards during my visit, I and the undersigned will cease all activity near or around said hazard and immediately alert the nearest Little Pinecones Play Cafe, LLC employee; I agree that all undersigned and I shall use all play equipment and items appropriately, adhering to all play rules, which include all size and weight limitations; I understand and agree that I will be solely responsible for any and all costs to repair or replace any damage to the facility and/or the equipment therein caused by the undersigned and myself outside of normal wear and tear.

3. I, for myself, and the participant(s) named herein below, acknowledge and understand that there are dangers and risks associated with the activities at Little Pinecones Play Cafe, LLC and agree to assume all risk of personal injury, including the potential for paralysis and death, and I, on behalf of myself and the participant(s) undersigned, knowingly and freely assume all such risk, both known and unknown, including those that may arise out of negligence of or conduct of other participants in Little Pinecones Play Cafe, LLC activities;

4. I, for myself, and the participant(s) named herein below, and on behalf of our heirs, assigns, administrators, pe representatives and next of kin, hereby agree to indemnify and release and hold harmless Little Pinecones Play Cafe, affiliates, officers, members, agents, employees, other participants, landlord, equipment manufacturers, and sponsoring agencies against any and all claims, injuries, liabilities, damages, or costs to person or property arising out of or related to our participation in any and all Little Pinecones Play Cafe, LLC programs, activities, parties, the use of play area and/or play equipment to the fullest extent of the law.