Tulsa Glassblowing School

123 Main St
My City, My State, 12345
Release Form

Date: 05/09/2014

WAIVER INFORMATION
RELEASE, WAIVER OF RIGHTS, AND AUTHORIZATION FOR USE OF IMAGE
Failure to present a properly executed form will result in denial of use of facilities and services by the
Tulsa Glassblowing Studio, Inc.
Students First Name
Kevin
Student's Last Name
Benkert
Is the Student a minor?
No
If YES, Students DOB
05/09/2014
if YES, Guardian First and Last Name
Address
5668 s. Delaware pl
City
Tulsa
State
Oklahoma
Zip
74105
Phone Number
9012997669
Email
Xietabink@aol.com
I would like to receive email updates about TGS. Please
add me to your mailing list.

ACKNOWLEDGEMENT
Tulsa Glassblowing Studio, Inc., an Oklahoma non-profit corporation under 42 U.S.C section 501(c)(3)
(hereinafter Sponsor), sponsors and conducts classes and seminars to instruct or enhance the
abilities of individuals to work with hot, molten glass and objects that are heated, sharp, and may
cause injury. In connection with such activities, Sponsor provides a location, facilities, instruction, and
equipment used or useful in creating or making glass items and for the advancement of education in
the use and manipulation of glass.
In consideration for the execution of this Release, Waiver of Rights, and Authorization for Use of Image
(hereinafter Agreement), Sponsor agrees to permit you or the minor on whose behalf this Agreement
is execute (hereinafter Student), to avail himself or herself of the use and enjoyment of the
equipment and/or instructional services of the agents or employees of Sponsor.
In order to use and enjoy the equipment and services you acknowledge and agree for yourself and/or
on behalf of Student that:
1.Working with or exposure to molten glass and glass is dangerous and could result in serious bodily
harm, temporary or permanent physical impairment or disability, and/or possibly death to the student
2.The equipment utilized in preparing and working with molten glass is subject to malfunction, failure
of components or improper use by the undersigned, other students, visitors, or third persons over
which Sponsor has no control.
3.In consideration of the right and authority license to use and access to Sponsors equipment and
facilities, Student or you on behalf of Student
a.Assumes all risk of injury or death to Student or any injury or damage to Students property
b.Waives and release every claim or cause of action of Student to TGS, its officers, directors,
employees, and guests that exist or arise at or on the Sponsors premises, INCLUDING, BUT NOT
LIMITED TO ANY CONSEQUENCE OF THE ACT OR OMISSION OF SPONSOR, ITS MEMBERS, AGENTS,
EMPLOYEES, CUSTOMERS, INVITEES, OR ANY OTHER PERSON OR ENTITY REQUIRED OR PERMITTED TO
BE ON THE SPONSORS PREMISES OR UTILIZE ANY OF THE EQUIPMENT OR SERVICES PROVIDED BY
SPONSOR.

Submitted by Janet Duvall at 05/09/2014 19:18 UTC, captured at 05/09/2014 18:46

Submission ID: 9458F4C9-1C64-41A3-8188-F54B26575B1F
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Tulsa Glassblowing School

123 Main St
My City, My State, 12345
Release Form

Date: 05/09/2014

4.You further agree and authorize Sponsor to use the image of Student in any manner or format
deemed appropriate by Sponsor, including but not limited to posting such images on the worldwide
web, in video, photographs, advertising, promotional material, educational material, magazine articles,
etc
5.You further represent that you:
a.Are more than 18 years of age OR, if signing on behalf of a student who is under 18 years of age, are
the parent or legal guardian and have full legal authority to sign this agreement;
b.Understand written English;
c.Have read, understand, and agree to the terms and conditions set forth in this agreement; and
d.Sign and deliver this Agreement to Sponsor freely, voluntarily, and without compulsion or pressure.
Signature of Student (if 18 or over), Parent, or Guardian

Date

05/09/2014

ITEM HOLDING
The Tulsa Glassblowing School will hold the items you create for NO LONGER than 30 days. After 30
days, the items may be put up for sale, donated, or recycled.
I acknowledge that the items that I create will be held
no longer than 30 days.

GENERAL INFORMATION
How did you hear about the Studio?

Submitted by Janet Duvall at 05/09/2014 19:18 UTC, captured at 05/09/2014 18:46

Submission ID: 9458F4C9-1C64-41A3-8188-F54B26575B1F
Mobile Apps For How You Do Business - powered by Canvas (www.gocanvas.com)

Page: 2