Waiver of Liability

Please print out and sign this waiver and present it on the day of the event for a stamp. You will not be allowed to perform without this signed Waiver of Liability and a General Photograhy Release on file.




 In exchange for permission to participate in POLEder Boulder dance events, I hereby enter into the following release and waiver of liability assumption or risk and indemnity agreement. I, for myself, my heirs, spouse, executors, administrators, personal representatives, and assignees, waive, release, discharge, indemnify, hold harmless and agree not to sue Vivienne Palmer and POLEder Boulder its officers, directors, shareholders, employees, agents, landlords, lessees, sponsors, representatives volunteers, affiliates, and franchisees (hereafter the “Released Parties”) from any and all liability, responsibility, damages, losses, claims, demands, actions, suits, judgments, costs and expenses (including attorney’s fees) resulting from personal injury, accidents, illness, death and/or property loss caused in any manner, including the simple, active or passive negligence of the Released Parties, by my participation in the POLEder Boulder dance events.

  • I acknowledge that POLEder Boulder dance events are designed to stress the heart, lungs, cardiovascular and circulatory systems, muscles, joints, ligaments and tendons in an attempt to improve muscular strength, flexibility, and cardiovascular fitness.
  • I acknowledge that warming up prior to engaging in POLEder Boulder dance events and stretching upon completion of these activities is important to my physical health and that I am responsible for doing so.
  • I acknowledge I have been advised to consult with my physician with respect to any past or present injury, illness, cardiovascular problem, joint problem or any other condition or medication that may affect my participation and ability to participate in and to endure any exercise programs, and knowingly assume all risks relating to my participation in the POLEder Boulder dance events.
  • I understand that POLEder Boulder staff are not qualified to teach prenatal fitness/movement and therefore, agree to not participate in POLEder Boulder dance events while pregnant.
  • I understand that POLEder Boulder dance events are designed for individuals 18 years and older, and therefore, I certify that I am at least 18 years of age.
  • I understand that it is unsafe for me and potentially risky to others to participate in POLEder Boulder dance events while intoxicated or impaired, and therefore, I agree that I will only participate when completely sober and unimpaired.
  • I release POLEder Boulder and Vivienne Palmer and Stacey Mulvey from any claims against injury caused by equipment failure (X-Pole X-Stage Lite), whether caused by negligence or improper use.
  • I certify that I have adequate insurance to cover injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk or any medical or physical condition I may have.

I acknowledge that I have discussed with my physician the appropriateness of POLEder Boulder dance events in connection with any illness or condition that I now have or have previously had, and that I will discuss any future illnesses or conditions with my physician prior to continuing any exercise programs. I acknowledge that I am personally financially responsible for any medical or other treatment needed as a result of my participation in the POLEder Boulder dance events.

I knowingly execute this agreement freely and voluntarily and intend this to be a complete and unconditional release of all liability to the greatest extent allowed by law.

I certify that I have read this agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. This agreement is intended to be as broad and inclusive as permitted by law. If any portion of this agreement is held invalid, the remaining portions will continue in full force and effect.


Participant Signature_________________________________________Date_______________


Participant Printed Name: _______________________________________________________

Click to download: Waiver POLEder Boulder

One thought on “Waiver of Liability

  1. Pingback: Welcome to the Second Annual Memorial Day POLEder Boulder 2013 | POLEder Boulder

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