LPC Member Waiver & Release Form

LPC Member Waiver & Release Form

Please complete all sections. Your acknowledgement and signature are required to participate. If under 18, a parent/guardian must also sign.
I acknowledge that I have read and understood this Agreement and voluntarily agree to participate.
Name (Acknowledgement Section)
Date (Acknowledgement Section)

MonthDayYear
Date
Member Full Name

First NameLast Name
Member Date of Birth

MonthDayYear
Date
Member Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Member Phone
Please enter a valid phone number.Format: (000) 000-0000.
Member Email
example@example.com
Member Signature
Member Signature Date

MonthDayYear
Date
Parent/Guardian Name (if member is under 18)
Relationship to Minor
Parent/Guardian Signature
Parent/Guardian Signature Date

MonthDayYear
Date
Should be Empty: