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[Name of Event/Program] Waiver and Release Form 20__

A PARENT, LEGAL GUARDIAN OR EMPOWERED REPRESENTATIVE OF EACH MINOR CHILD(REN) REGISTERING TO ATTEND
[Name of Event/Program] MUST AGREE TO THE TERMS OF THIS WAIVER AND RELEASE OF LIABILITY AND NAME AND
LIKENESS PRIOR TO THE CHILD(REN) PARTICIPATING IN THE [Event, camp, program, etc].

Child’s Name:_______________________________ DOB _____________ Age _____

Mother: __________________________ (Cell) ________________ (H) ______________
Father: __________________________ (Cell) _________________ (H) ______________

Child lives with: __ mother __ father __ both Email: _______________________________________

____ By checking here I give [your name, your school’s name, or your organization’s name] permission to have my child
appear in media and understand this is for professional use only.
Rest assured, your child’s safety is of the highest importance. It is our goal to ensure your child feels physically safe, en-
couraged and nurtured. Yet, injuries can occur. In the unlikely event of an emergency, we will make every attempt to con-
tact you immediately.

Signature_________________________________________ Date: _____________________
Emergency Contact:________________________________Phone: _____________________

2nd Emergency Contact:____________________________Phone: _____________________
Doctor: ___________________________________________ Phone: ____________________
_____________________________________________________________________________________

_____________________________________________________________________________________

(Child’s allergies, injuries, behavioral concerns)

____ My child is in good health and in proper physical and mental condition to participate in such activity.

____ I acknowledge that if I believe event conditions are unsafe, I will immediately discontinue my child’s participation in
the activity.

____ I fully understand that this activity involves risks of illness, bee stings, bodily injury, including strains, sprains frac-
ture, dislocation, permanent disability, paralysis and death- that may be caused by my own child’s actions, or inactions,
those of other participant’s, or the negligence of the “releasees” named below; and that there may be other risks either
not known to me or not readily foreseeable at this time;
___ Medical Treatment: In connection with any injury my child(ren) may sustain or illness or other medical conditions my
child(ren) may experience during his and/or her participation in or attendance at the [Name of Event/Program], I author-
ize any emergency first aid, medication, medical treatment or surgery deemed necessary by the attending medical per-
sonnel if I am not able to act on my child’s behalf. (Continued on reverse)

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