WAIVER OF LIABILITY, ASSUMPTION OF RISK & INDEMNITY AGREEMENT
**DO NOT fill out this waiver if you have previously done so**
Child Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Child Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Child Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Child Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Adult
*
First Name
Last Name
Adult
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Home/Work/Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please review before signature
Publicity/Privacy Release
*
Yes
No
Signature
*
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Emergency Contact (If different than Parent)
Name
Relationship
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