2022 Diaper Derby Registration

2022 Diaper Derby Registration

If you have questions or need help completing this online registration, please call 270-717-5433.
Parent/Guardian Information
Parent/Guardian Name *

First Name Last Name
Your relationship to child/children you are registering for *
Address *

Street Address

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Would you like information on how to gain valuable parenting education while earning diapers, wipes, and other baby supplies? *
Do you attend Church regularly? *
Child/Children Information

*PLEASE NOTE: IF YOU ARE REGISTERING MORE THAN 2 CHILDREN, PLEASE SUBMIT MULTIPLE FORMS
Child 1 Name *

First Name Last Name
Does this child crawl or walk? *
Birth Date *

Month Day Year
Age *
Gender *

Male Female
Child 2 Name (If applicable)

First Name Last Name
Does this child crawl or walk?
Birth Date

Month Day Year
Age
Gender

Male Female
WAIVER TO PARTICPATE I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH THIS EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.

Waiver to the maximum extent permissible under applicable law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

I acknowledge that Life Choice or the Logan County Fair Board and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts or failures to act of any party or entity conducting a specific activity on their behalf.

I acknowledge that this activity may involve a test of a person's physical and mental limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, volunteers, monitors, and/or producers of the activity. These risks are not only inherent to participants but are also present for volunteeers.

By this WAIVER AND RELEASE, I assume any risk, and take full responsilbility and warranty of any and all claims of personal injury and death or damages to but not limited to my use of the Release Parties' facilities and/or engaging in the Release Parties' activities or other activities on and near the Release Parties' premises on the date the house(s) are used. Parties Include: Life Choice Pregnancy Care Center, Logan County Schools Family Resource Youth Service Centers, Logan County Fair, Local Churches and Volunteers.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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