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									                                 The Blue Bounce House
                                 Mary Alex, Proprietor
                                     P O Box 1225
                                 Millbrook, NY 12545

Dear Parents & Guardians,

   I have donated the use of an inflatable obstacle course & slide for the students of Elm Drive
Elementary School to enjoy on Monday, June 20, 2011. Because there are potential risks involved
while playing on a Bounce House unit, I ask that you complete and return the attached hold harmless
form in order for your child to participate.

   Please be assured that the Blue Bounce House has insurance and that we follow all suggested
safety measures suggested by the manufacturer and amusement industry.

   Feel free to visit our website: to see what services we provide! If
you have any questions, please do not hesitate calling me at 845-337-1890.

Mary Alex

My child, ______________________________________, has permission to participate with the
inflatable obstacle course and slide/or bounce house at Elm Drive Elementary School on Monday,
June 20, 2011. I understand that there are potential risks to my child including, but not limited to
injury, bumps, scrapes, broken bones, head, neck or spinal injuries, paralysis or death. If my child
suffers from any risk as an involvement in the use of an inflatable device, I hereby hold harmless
The Blue Bounce House its owners and staff, Elm Drive Elementary School and staff, and the
Millbrook Central School District staff and Board of Education, from any and all claims that may
arise from the use of the inflatable device.

___________________________________________                 _______________
Signature of Parent or Guardian                             Date

Teacher__________________________________ Grade______________________

Address___________________________ Town________________ Zip__________

Email_______________________________________ Phone_____________________

Cell Phone________________________ Alt. Phone #___________________________
___ Please send me special offers throughout the year.

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