Activity Consent Form

International Mud Day

June 29th & 30th
Participant Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Age
Address

Street Address

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I, undersigned, agree with the following statements:

I am giving my consent in case of an emergency involving my child, and in the event I cannot be reached, medical provider can secure propertreatment, including hospitalization, anesthesia, surgery, or injections of medication for my child.Medical providers are authorized to disclose protected health information to the adult in charge and/or any physician or health care provider involved in providing medical care to the participant.With appreciation of the dangers and risks associated with programs and activities including preparations for and transportation to and from the activity, on my own behalf and/or on behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against the organization, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity.
Parent/Guardian Name (If Applicable)

First NameLast Name
Date

MonthDayYear
Date
Signature

2 years and Under

Free

Over 2 years

Please enter coupon code Cash if paying in person

$10.00

Enter coupon

Total

Payment Methods

Choose from one of the PayPal options to make your payment.
Should be Empty:

International Mud Day