Page 11 - Kids and Bees Resource Booklet_SP_Neat

[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, encouraged and nurtured. Yet, injuries can occur. In the unlikely event of
an emergency, we will make every attempt to contact 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, in-
cluding strains, sprains fracture, 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

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