Class Participation/Waiver Form:

Class*

Location*

Time*

Name of Participant*

Age*

Date of Birth*

Date

Parent/Guardian Name*

Phone Number*

Email Address*

example@example.com

Emergency Contact Name *

Emergency Contact Phone Number*

Relationship to child*

Does the participant have any medical problems/allergies that the instructor should be aware of?If Yes, Please Specify:

Does the participant have any behaviors or needs that the instructor should be aware of? If Yes, Please Specify:

Is there anything else you would like to tell us about the participant?

Please note that unless specified otherwise all Puddle of Mud classes are unparented. Children must be fully potty-trained and meet the age requirements of a class unless they have an exception note from a POM instructor. Students also must be able to follow all instructions given by the instructor and adhere to the safety policies provided by the instructor in regards to physical distancing and safety. Inability to follow these instructions may result in removal from class.

I understand that participation in the above mentioned event, activity or program could include activities that involve inherent risks, dangers and hazards both known and unknown, that are associated with unique movement patterns and skills. By signing below I agree to participation and release the organization above from all liability, costs and damages which could arise from participation in the above named event.

Iunderstand that if the child and/or guardian bringing them is feeling unwell at all, with any symptoms including: fever, cough, shortness of breath or any symptoms that have been deemed relevant by AHS, WHO or any other government organization-they cannot attend class that day. I also understand that the instructor of the class may ask the student to leave if such symptoms are apparent. I have read all applicable illness policies.

By signing below I agree to participation and release the organizations above from all liability, costs and damages which could arise from participation in the above named event.

In consideration of being allowed to participate in the Puddle of Mud Productions program and activities,I hereby agree as follows: To waive any and all claims that I have or may have in the future against, and to release and discharge from any and all liability, Puddle of Mud Productions, it's directors, officers, employees, consultants, agents, contractors, volunteers, and representatives, and their respective successors and assigns, or any of them in connection with or participation in the Puddle of Mud Productions program, for any and all of the following: Personal injury; Death; Property damage; and/or Any other loss, damage or expense, arising from any cause whatsoever, including negligence (including, but not limited to, negligence caused by my own actions or inactions, those of others participating in the activities, the conditions in which the activities take place, or negligence of Puddle of Mud Productions), and further including the failure on the part of the Puddle of Mud Productions to take reasonable steps to safeguard or protect me from the risks, dangers and hazards of participating in Puddle of Mud Productions program and activities.

I would like to be added to Puddle of Mud Productions mailing list. (Emails are sent out approximately once every 1-2 months)and agree to having emails sent to the email address provided above.*

YesNo

I hearby grant permission to Puddle of Mud Productions to use my/my child's likeness in photographs, video and in any and all of its publications and in any and all other media, whether now known or hereafter existing controlled by Puddle of Mud Productions in perpetuity, and for other use by Puddle of Mud Productions. I will make no monetary or other claim against Puddle of Mud Productions for the use of the photographs/video.*

YesNo

Signature of Participant (if over 18 yrs)

Date

Name of Parent or Guardian*

Date*

Date

Signature of Parent or Guardian*

Witness

How did you hear about our programs?