Summer Fun Days

Child's Name *

First Name

Last Name

Child's Birthday

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

What day(s) are you interested in? *

Tues. June 10th

Wed. June 11th

Thurs. June 12th

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

I hereby solely and expressly assume liability for all risks and waive any claim I might have against Kristin Evans or individuals acting in the capacity as agents of the organization (staff members, independent contractors, volunteers, etc.). I assume full legal liability for my child’s actions on campus and release Kristin Evans and agents acting on their behalf from any claims made as a result of my child's actions. This release shall be effective and binding upon the parties, as well as their heirs, beneficiaries, assigns, successors and legal representatives. *

By checking the box, I acknowledge that I have read and understand this release.

Electronic Signiture *

By entering your name below, you agree to the conditions set forth in this form.

First Name

Last Name