Note: If you'd like a printed version of this form, you can download it HERE.

Due to the current Covid-19 pandemic, all individuals must read, sign, and have a parent or guardian read and sign the waiver below. If the waiver is not signed, individuals cannot attend Break events.

The novel coronavirus, (COVID-19), has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of large groups of people. The BREAK is operating in compliance with Phase 4 of the State of Illinois’ Restore Illinois reopening plan regarding COVID-19, in the conducting of events and activities at the center. Please visit our site FAQ to read our protocols. Unfortunately, The Break cannot guarantee that our members and volunteers will not become infected with COVID-19. In consideration of member participation in any events at The Break, the undersigned declares the following: I am fully and personally responsible for my own safety and actions while and during my participation and I recognize that in any case I may be at risk of contracting COVID-19. With full knowledge of the risks involved, I hereby release, waive, discharge The Break, their staff, agents, volunteers, and co-sponsors and affiliates, from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19. I agree to indemnify, defend, and hold harmless The Break, their staff, agents, volunteers, and co-sponsors and affiliates, from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19. By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old (parental signature required if under 18) and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation. This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.

Participant's Signature

Parent/Guardian Signature

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Physical address: 

6292 Northwest Highway 

Crystal Lake, IL 60014

Mailing address:

PO Box 192

Crystal Lake, IL  60039-0192



Monday:               4:00 - 8:00
Wednesday:         4:00 - 8:00
Friday:                6:00 - 10:30

The BREAK is a 501 C 3 non-profit organization.
© 2021 by The Break.
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