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1366 Startown Rd

Lincolnton, NC 28092

D-Xperience Accidental Waiver Form

On behalf of my child's name listed above, I hereby give permission for my child to participate in D-Xperience. I acknowledge that my child’s participation in this program is a learning experience and a safe place for my child to go for all programs offered is not part of the regular school curricular program. 

I hereby release, absolve, indemnify, and hold blameless to their directors, employees, instructors, and volunteers of any and all liability for damage, injury, or expense of any kind arising out of or connected with my child’s participation.. I understand that in case of a medical emergency, my own personal medical plan will be used if available; if not, medical aid may be sought while I am being contacted. In the event of any illness or injury, I hereby consent to whatever examination, diagnosis, or treatment and the hospital care from a licensed dentist, physician, and/or surgeon as deemed necessary for my child’s safety and welfare. I understand that the resulting expenses will be my responsibility and not D-Xperience. As a condition of participation in the after school program by the student named in this application, I acknowledge that I have read this consent form, and knowingly, on behalf of my child, assume all of the risks associated with participating in any way in D-Xperience. 

As consideration for being permitted to participate in the after school enrichment program, I hereby agree that I, my assignees, heirs, distributes, guardians, and legal representatives will not make claim against, sue or attach the property of D-Xperience, or their Affiliates or the supplier of any of the equipment used in these activities for injury or damage resulting from negligence, failure of care, omission or other acts, howsoever caused by an employee, agent or contractor of D-Xperience and any affiliate as result of incidental to my child participation in these activities. I hereby release, to the fullest extend permitted by law, D-Xperience and the affiliates, from any and all actions, claims, demands, or liabilities that I, my assignees, heirs, distributes, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my son/daughter participation in these activities irrespective of whether the same is based on breach of warranty, negligence, strict liability or any other theory or recovery. 

Parent/Legal Guardian acknowledges that D-Xperience is not a licensed childcare or daycare facility. 


I have read this agreement and agree to the conditions stated above.


Thanks for submitting!

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