Black Girls Code
Release of Liability and Assumption of Risk Agreement
This is a release. Read it carefully before signing. This release essentially states that I know that I will be engaging in
activities related to Black Girls Code. As a result of the inherent risks in this activity, I know I may be susceptible to
harm, injury, or die and that my belongings may be lost, misplaced, damaged, or stolen. If any of these occur, I
understand that I cannot make a claim, sue, or expect Black Girls Code, their owners, officers, agents, employees,
and/or associates (hereinafter referred to as Black Girls Code or “BGC”) to be legally responsible or pay for any
damages.
I, _________________________ , Customer, voluntarily sign this Waiver and Assumption of Risk in favor of Black
Girls Code, _________________________ , inconsideration for the opportunity to use the Owner's facilities and/or the
opportunity to receive instruction from the Black Girls Code or the Black Girls Code employees, and/or to engage in
the activities sponsored by the Black Girls Code, as follows:
I understand that there are certain risks and dangers associated with the activity and use of the
facilities and that these risks have been fully explained to me. I fully understand the danger involved.
I fully assume the risks involved as acceptable to me and I agree to use my best judgment in
undertaking these activities and follow all safety instructions.
I waive and release the Black Girls Code from any claim for personal injury, property damage, or death that
may arise from my use of the facilities or from my participation in the activities or instruction.
I am a competent adult, aged _________________________ , and I assume these risks of my own free will.
I HAVE READ THIS DOCUMENT IN ITS ENTIRETY. I UNDERSTAND THAT I AM ASSUMING ALL
THE RISKS INHERENT IN THIS BLACK GIRLS CODE ACTIVITY. I UNDERSTAND THAT IT IS A
RELEASE OF ANY AND ALL CLAIMS. I UNDERSTAND THAT THIS IS THE ENTIRE AGREEMENT
BETWEEN THE UNDERSIGNED AND BLACK GIRLS CODE, THEIR OWNERS, OFFICERS, AGENTS,
AND EMPLOYEES AND IT CANNOT BE MODIFIED OR CHANGED IN ANY WAY BY
REPRESENTATIVES OR STATEMENTS BY BLACK GIRLS CODE OR BY THE UNDERSIGNED. I
VOLUNTARILY SIGN MY NAME AS EVIDENCE OF MY ACCEPTANCE OF ALL THE PROVISIONS IN
THIS RELEASE AND MY AGREEMENT TO BE BOUND BY THEM.
Dated: _________________________ , 20 ___
_________________________
Signature of Customer
_________________________
Printed Name of Customer
PARENTS AND GUARDIAN’S ADDITIONAL INDEMNIFICATION (MUST BE COMPLETED FOR
PARTICIPANTS UNDER THE AGE OF 18)
In consideration of ______________________________ (Print Minor’s Name) (“Minor”) being permitted by Black
Girls Code to participate in its activities, I further agree to indemnify and hold harmless Black Girls Code, from any
and all claims which are brought by, or on behalf of Minor, an which are in any way connected with such use of
participation by Minor.
Signature of Parent or Guardian__________________________________________________
Print Name_____________________________________________ Date ________________