ICS March Activities Registration Form

ICS March Activities Registration Form
Participant's Full Name*

First NameLast Name
Participant's Date of Birth*

MonthDayYear
Date
Participant's Email Address, if applicable.
example@example.com
Participant's Phone Number, if applicable.
Please enter a valid phone number.Format: (000) 000-0000.
Volunteer for Easter Egg Assembly, Saturday March 7th, 9AMShamrock Run 5K, Sunday March 8th, 9AM (Speak with Lisa Morrison directly, also.)Art Group, Wednesday March 11th, 6PMPokemon & Puzzle Club, Saturday March 14thth, 3PMMovie Club, Sunday March 15th, 3PMGame Night, Wednesday March 18th, 6PMVolunteer to Assemble Care Bags, Friday March 20th, 6PMLittle Oregon 5K, Saturday March 21st, 9AM (Speak with Lisa Morrison directly, also.)Art Group, Wednesday March 25th, 6PMDessert at Dairy Queen, Friday March 27th, 6pmFitness Class, MWF 3PM (Speak with Lisa Morrison, also.)
Floral Design, LIMITED SEATING, Saturday March 28th, 3pm
Yes
Guardian's Full Name. If participant does not have an appointed Guardian, please enter participant name.*

First NameLast Name
Guardian's Relationship to Participant. If participant does not have an appointed Guardian, please select Self.*
Guardian's Email Address. If participant does not have an appointed Guardian, please enter participant's email, or other email we may contact.*
example@example.com
Guardian's Phone Number. If participant does not have an appointed Guardian, please enter participant's phone number.*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Integrated Community Solutions, Inc.

Waiver, Release and Hold Harmless Agreement

I (the Participant) have been offered the opportunity to participate in and/or volunteer to help with social activities organized by Integrated Community Solutions, Inc., (ICS) a non-profit Ohio charitable corporation. I want participate in ICS programs because it gives me pleasure and satisfaction to be involved with others who are developmentally disabled, or who are family and friends of people with developmental disabilities. I fully understand and accept the risks involved in these activities.

As consideration for being provided this valuable opportunity, I will hold harmless and indemnify ICS, its directors, agents, volunteers and employees, from any and all losses, claims, actions or proceedings of every kind and character, including claims for negligence and for damages of any kind, including damage to property, personal injury or death which may arise directly or indirectly from my presence at ICS locations, and my participation in ICS activities. I agree to abide by all policies, procedures and instructions adopted by ICS as they may change from time to time.

I understand that ICS will take pictures and videos during various social engagement opportunities. I give ICS permission to use my likeness, photo, video to promote ICS, and raise funds for the organization. I understand that I will not be compensated for this. If I do not agree to this, I will discuss this with the group coordinator.
Select if you read the ICS Waiver Agreement and agree with its terms.
If this Agreement is executed by a parent of a minor Participant, I certify that I am the parent or legal guardian of the minor and accept its terms on the minor’s behalf.If this Agreement is executed by a current legal guardian of the Participant, I certify that I have been duly appointed as the Participant’s guardian by a court of competent jurisdiction and accept its terms on the participant’s behalf.If I am an adult Participant without a court-appointed guardian, I certify that I am at least 18 years of age, have the legal capacity to enter into this Agreement and accept its terms on my own behalf.
Signature*
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: