POLE & LOLLIPOP PARTICIPATION WAIVER AND RELEASE OF LIABILITY
Sparkle N Flow Entertainment LLC x Spread The Flow LLC x Riptidez
Event/Jam Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Venue
*
Participant Information
Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Signature
*
Printed Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is the participant under 18 years of age?
*
Yes
No
For Participants Under 18
I am the parent or legal guardian of the minor participant named above. I have read and understand this agreement and consent to the minor's participation.
Full Name-Parent/Legal Guardian Name
First Name
Last Name
Parent/Legal Guardian Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Continue
Continue
Should be Empty: