Please read this entire document carefully and completely before signing.
A separate form must be completed for each student participating in Atlantis Chess Club.
Required for all students before the first session.
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF ATLANTIS CHESS CLUB AND THE RELEASED PARTIES IDENTIFIED IN THIS WAIVER USE REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED.
BY SIGNING THIS FORM, YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM ATLANTIS CHESS CLUB AND THE RELEASED PARTIES IDENTIFIED IN THIS WAIVER IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY.
YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND ATLANTIS CHESS CLUB HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
The activity covered by this Waiver is participation in Atlantis Chess Club (the “Activity”), a structured youth chess program for students ages 6–17. The Activity takes place at:
The Activity includes, but is not limited to, structured chess lessons, group match play, Chess Challenges, Monthly Open Play, seasonal tournaments, and related club activities and events.
I understand that participation in the Activity involves risks inherent to structured group programs conducted at shared community facilities. These risks include, but are not limited to:
I acknowledge that it is not possible to identify every individual risk associated with the Activity, and that risks other than those listed above may exist.
In consideration for Atlantis Chess Club’s permission to allow my minor child to participate in the Activity, I, on behalf of myself and my minor child, expressly, knowingly, and voluntarily assume all risks of injury, death, property damage, or other harm arising out of or related to my child’s participation in the Activity, including the inherent risks described in Section 2 above and all other risks that may arise from participation.
I represent and warrant that my child is in satisfactory physical and mental condition to participate in the Activity. I agree to notify Atlantis Chess Club promptly in writing if my child’s physical or mental condition changes in a way that may affect safe participation.
In consideration for Atlantis Chess Club’s permission to allow my minor child to participate in the Activity, I, for myself and on behalf of my minor child, and for our respective personal representatives, executors, administrators, heirs, next of kin, successors, and assigns, hereby voluntarily and knowingly:
(a) RELEASE, WAIVE, DISCHARGE, and COVENANT NOT TO SUE Atlantis Chess Club, its owners, directors, officers, coaches, instructors, staff, employees, volunteers, agents, representatives, facility partners, successors, and assigns (collectively, the “Released Parties”) from all liability, claims, demands, actions, causes of action, suits, and damages of any kind, whether known or unknown, arising out of or related to my child’s participation in the Activity, including claims arising from the ordinary negligence of the Released Parties; AND
(b) AGREE NOT TO BRING any claim, lawsuit, or legal proceeding against any Released Party arising out of or related to my child’s participation in the Activity, to the extent permitted by applicable Florida law.
IMPORTANT LIMITATION: This release does not apply to, and the Released Parties are not released from, any claims arising from gross negligence, willful misconduct, reckless disregard for safety, or intentional acts by any Released Party. Nothing in this Waiver limits any rights provided to you or your child under applicable Florida law that cannot be waived or released by contract.
To the fullest extent permitted by applicable law, I agree to defend, indemnify, and hold harmless the Released Parties from and against any claims, damages, losses, costs, and expenses (including reasonable attorneys’ fees) arising from: (a) inaccurate, false, or incomplete information I provide to Atlantis Chess Club; (b) my own conduct at or in connection with the Activity; (c) my child’s conduct at or in connection with the Activity; or (d) my failure or my child’s failure to follow program policies, procedures, or rules.
This indemnification does not apply to claims arising from the gross negligence, willful misconduct, or intentional acts of any Released Party. This indemnification obligation survives my child’s disenrollment or dismissal from Atlantis Chess Club programs.
I authorize Atlantis Chess Club staff, coaches, volunteers, and facility personnel to administer available first aid to my child as they deem reasonably necessary in the event of an injury or medical situation during or in connection with the Activity.
I further authorize emergency medical transportation to a medical facility or hospital for treatment of any injury, illness, or medical emergency my child may experience while participating in the Activity. I acknowledge that any and all costs, fees, charges, and expenses incurred from emergency medical services, transportation, emergency department care, hospitalization, or any other emergency response are my sole financial responsibility.
Atlantis Chess Club is not a medical provider and does not provide medical diagnosis, treatment, or individualized medical care. I agree to disclose in writing any medical conditions, allergies, medications, or health concerns that may affect my child’s safe participation.
I understand that Atlantis Chess Club is not a medical provider, childcare center, school, clinic, or provider of individualized medical, therapeutic, behavioral, or disability-support services. Atlantis Chess Club staff, coaches, and volunteers do not provide medical monitoring, medication administration, restroom assistance, one-on-one care, or specialized supervision unless expressly agreed in writing.
I am responsible for determining whether my child can safely participate in the program environment and for disclosing any medical, allergy, behavioral, developmental, disability-related, or support information that may affect my child’s safe participation.
This Waiver and Release applies to each and every program session, event, tournament, open play session, and other Atlantis Chess Club activity in which my child participates, at any location, without requiring me to sign a separate form for each individual session or activity. This Waiver and Release is binding from the date of signing and applies for the full duration of my child’s enrollment in Atlantis Chess Club programs, including any re-enrollment periods.
If this Waiver and Release is signed or accepted electronically, including by typing my name, checking an agreement box, or submitting an online form, such electronic signature or acceptance constitutes my legal signature and has the same legal effect as a handwritten signature in accordance with Florida’s Uniform Electronic Transactions Act (Fla. Stat. § 668.50) and the federal E-SIGN Act (15 U.S.C. § 7001 et seq.).
This Waiver and Release is governed by the laws of the State of Florida, without regard to conflict of law principles. Exclusive jurisdiction for any dispute arising out of or relating to this Waiver and Release shall lie in the Circuit Court of the Nineteenth Judicial Circuit, in and for St. Lucie County, Florida. If any provision of this Waiver and Release is found to be unenforceable or invalid by a court of competent jurisdiction, the remaining provisions shall continue in full force and effect.
I declare that I have read this Waiver and Release completely and carefully. I have had the opportunity to ask questions and any questions I have asked have been answered to my satisfaction. I am not acting under duress, coercion, or undue influence. I understand the risks of my child’s participation in the Activity and knowingly and voluntarily agree to this Waiver and Release on behalf of myself and my minor child.
I understand that Atlantis Chess Club does not provide restroom assistance, toileting assistance, changing assistance, medication administration, feeding assistance, or other personal care services. My child must be able to use the restroom and manage personal care needs independently, unless Atlantis Chess Club has expressly agreed otherwise in writing.
I REPRESENT THAT I AM THE PARENT OR LEGAL GUARDIAN OF THE MINOR CHILD NAMED BELOW AND THAT I AM FULLY COMPETENT TO EXECUTE THIS WAIVER AND RELEASE. I EXECUTE THIS DOCUMENT FREELY AND VOLUNTARILY AND FULLY INTEND TO BE BOUND BY ITS TERMS.
Parent/Guardian Full Name (Print): _____________________________________________
Parent/Guardian Signature: __________________________________________
Date: _____________________________________________
Minor Child’s Full Name (Print): _____________________________________________
Minor Child’s Date of Birth: _____________________________________________
Required for all students before the first session. Please print clearly.
A separate form must be completed for each student.
Program the student will be attending (select one):
☐ Port St. Lucie Juniors
☐ Fort Pierce Juniors
☐ Fort Pierce Teens
Club location (select one):
☐ Port St. Lucie
☐ Fort Pierce
Student First and Last Name: _____________________________________________
Student Age: _____________________________________________
Student Date of Birth: _____________________________________________
Parent/Guardian Full Name: _____________________________________________
Phone Number: _____________________________________________
Email Address: _____________________________________________
Students will only be released to a parent, legal guardian, or an authorized adult listed below. Identification may be requested before a student is released. I acknowledge that Atlantis Chess Club may contact the persons listed below, facility staff, or emergency services if needed for my child’s safety.
Emergency Contact Name: _____________________________________________
Emergency Contact Phone Number: _____________________________________________
Relationship to Student: _____________________________________________
Authorized Pick-Up Adult #1 — Name: _____________________________________________
Authorized Pick-Up Adult #1 — Phone: _____________________________________________
Authorized Pick-Up Adult #2 — Name: _____________________________________________
Authorized Pick-Up Adult #2 — Phone: _____________________________________________
Authorized Pick-Up Adult #3 — Name: _____________________________________________
Authorized Pick-Up Adult #3 — Phone: _____________________________________________
How was registration for this student completed? (select one)
☐ City of Port St. Lucie registration portal
☐ Atlantis Chess Club registration/payment form
☐ Not sure
Please select the student’s current chess experience level (select one):
☐ New to Chess — Still learning the pieces
☐ Beginner — Knows how the pieces move
☐ Intermediate — Can play a full game
☐ Advanced — Uses strategy or has tournament experience
☐ Not sure
Has the student previously taken chess lessons or participated in a chess club?
☐ Yes
☐ No
Please provide any allergies, medical conditions, behavioral concerns, support needs, or other information that may affect the student’s safe participation in the program:
Health / Special Notes (or write “None”): _____________________________________________
I acknowledge that students may not attend Atlantis Chess Club if they are sick or showing symptoms of illness, including coughing, sneezing, runny nose, fever, vomiting, diarrhea, or signs of a contagious illness.
Photo/video use, if permission is granted, may include club updates, website content, flyers, social media, newsletters, awards, and promotional materials.
Photo/video permission is optional and is not required for my child to participate in Atlantis Chess Club. If I decline photo/video permission, Atlantis Chess Club will not knowingly use my child’s image or recording for public, promotional, or external purposes. I may update or withdraw photo/video permission for future use by contacting Atlantis Chess Club in writing.
Please select one:
☐ Yes, I give Atlantis Chess Club permission to photograph and/or record my child for the uses described above.
☐ No, I do not give photo/video permission.
Please share how you learned about Atlantis Chess Club (select all that apply):
☐ City website
☐ Port St. Lucie Community Center
☐ Havert L. Fenn Center
☐ Flyer
☐ Facebook
☐ Instagram
☐ Friend or family member
☐ School
☐ Community event
☐ Other: _______________
By signing below, I confirm and acknowledge the following:
By signing below, I acknowledge that I have read, understood, and agree to be bound by the following Atlantis Chess Club documents:
These documents are available at https://atlantischessclub.com/parent-guardian-waiver/. Copies may be requested by emailing members@atlantischessclub.com.
This form must be completed in full before the student joins any class or program area. A student may not participate in Atlantis Chess Club until this form has been submitted by a parent or legal guardian. A separate form must be completed for each student.
Parents and guardians are responsible for updating Atlantis Chess Club whenever contact information, emergency contact information, authorized pick-up adults, health notes, allergies, or support needs change.
I represent and warrant that I am the minor child’s natural guardian, parent, legal guardian, or other person with legal authority to register the child and sign this Waiver and Release on the child’s behalf. I agree to provide Atlantis Chess Club with any court order, custody order, guardianship document, or legal restriction that may affect registration, participation, communication, emergency contact authority, or authorized pick-up.
I understand that Atlantis Chess Club is not responsible for resolving custody, guardianship, or family-law disputes and may rely on the information I provide unless Atlantis Chess Club receives a valid written legal order and has a reasonable opportunity to review it.
Parent/Guardian Full Name (Print): _____________________________________________
Parent/Guardian Signature: __________________________________________
Date: _____________________________________________
Student Full Name (Print): _____________________________________________
Questions? Email members@atlantischessclub.com or text 786-436-1434.
