Notes : ( * ) The required data

By checking this box, I further acknowledge and accept the terms and conditions of this waiver, release, hold harmless and indemnification agreement as detailed in 1 through 7 above for any and all future visits during the next twelve (12) month period. Please keep this waiver, release, hold harmless and indemnification agreement on file and active, for the participants and parent/guardian listed above, for a period of twelve (12) months from the date of acceptance.


Location Name :
 


Parent / Guardian / Sole Participant's Name :
 
1- Child's Name :  
Date of Birth :  
2- Child's Name :
Date of Birth :
3- Child's Name :
Date of Birth :
4- Child's Name :
Date of Birth :
5- Infant's Name :
Date of Birth :
6- Infant's Name :
Date of Birth :

Email address :
 
 
Address :
 
 
 
 
Phone Number :