Pops Play Studio Waiver
Please complete this form to allow your child to participate in the specified activity and acknowledge the waiver of liability.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Gender
Please Select
Male
Female
Non-binary
Prefer not to say
Other
Child’s Full Name
First Name
Last Name
Child’s Date of Birth
-
Month
-
Day
Year
Date
Child's Gender
Please Select
Male
Female
Non-Binary
Prefer not to say
Other
Child’s Full Name
First Name
Last Name
Child's Birthday
-
Month
-
Day
Year
Date
Child’s Gender
Please Select
Male
Female
Non-Binary
Prefer not to say
Child's Full Name
First Name
Last Name
Child's Birthday
-
Month
-
Day
Year
Date
Child's Gender
Please Select
Male
Female
Non-Binary
Prefer not to say
Child's Full Name
First Name
Last Name
Child's Birthday
-
Month
-
Day
Year
Date
Child's Gender
Please Select
Male
Female
Non-Binary
Prefer not to say
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child(s)
*
Please Select
Mother
Father
Legal Guardian
Other
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any allergies, medical conditions, or special needs your child has (if none, enter 'None')
*
Name of Activity or Event
*
Date of Activity or Event
*
-
Month
-
Day
Year
Date
Parent/Guardian Signature (please sign below to acknowledge and consent)
*
Submit Waiver
Submit Waiver
Should be Empty: