Vision of Hope Fishing Rodeo

REGISTRATION

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE STRICTLY CONFIDENTIAL AND WILL BECOME PART OF YOUR CONSULTING RECORD.
Participant Name
Contact Name
Age
Address
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Communication
T-shirt Size
OTHER PROGRAMS OF INTEREST

If your child is 16 years and older, would you like Vision of Hope to contact you to discuss other programs and activities? If yes, mark the programs of interest below.
Type a question

Other
If your child is between the ages of 14 and 21, would you be interested in attending a Career Camp approved by Vocational Rehabilitation during school breaks?
ALL PARTICIPANTS MUST BE ACCOMPANIED BY A PARENT OR GUARDIAN AT ALL TIMES.
Participant Signature
Parent/Guardian Signature
WAIVER OF RELEASE AND LIABILITY
READ BEFORE SIGNING
I, the undersigned, understand that my participation in the Vision of Hope, Inc. Fishing Rodeo, related events and activities, acknowledges, appreciates, and agrees that: 1. I knowingly and freely assume all potential risks involved with participation in this event, known and unknown, even if arising from the negligence of the releases or others, and assume full responsibility for my participation, 2. I willingly agree to comply with the stated and customary terms and conditions for participation. If however, I observe any unusual, significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately, and, 3. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Vision of Hope, Inc., their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners (Robert & Kirsten Deka) and lessors of premises used to conduct the event ("RELEASES"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASES OR OTHERWISE. I HAVE READ THIS

RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THATI HAVE G IVEN UPALL SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Participant Name
Participant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Name
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
AUTHORIZATION FOR USE OF PHOTOGRAPHY/VIDEO/IMAGE
Participant Name
Pictures and videos taken during this event may be used by local newspapers, television stations, Facebook, websites, etc. In order to have your (or your thild's/ward's) picture used, authorization is needed. Please read the following consent below. I/We, the undersigned, hereby consent to the use of any video, photograph, slides, audio, tape, or any other audio or visual reproduction in which the above-named individual may appear, including but not limited to audio or video posted to the Vision of Hope, Inc. website or on Vision of Hope, Inc. promotional material. I/we understand and agree to any such image or audio/visual material being identified as that of the above-named individual. I/we understand that these materials may be used, without compensation, for promotional purposes including recruitment and fundraising efforts or general publication. Promotion may include, but is not limited to, slide presentations, photo displays, internet promotion, electronic multi-media, television, radio or billboard display. I/we agree that the photograph/image/video: shall be free for use and hereby release and hold harmless Vision of Hope, Inc. it's employees, volunteers, and agents for any liability connected with the use of said photograph/image/video. Yes, give permission to use my (or my child's/ward's) picture. No, do not give permission to use my (or my child' s/ward's) picture.
Yes, I give my permission to use my (or my child's/ward's) picture.
No, I do not give my permission to use my (or my child' s/ward's) picture.
Participant's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

OTHER PROGRAMS OF INTEREST

WAIVER OF RELEASE AND LIABILITY

READ BEFORE SIGNING

AUTHORIZATION FOR USE OF PHOTOGRAPHY/VIDEO/IMAGE