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Child's Birth Date
Event is for kids age 6 - 11 years old.
Parent or Guardian's Name
Parent/Guardian Phone Number
Address Line 2
State / Province / Region
ZIP / Postal Code
Additional Emergency Contact Name
Relationship to Child
Phone (Emergency Contact)
Allergies or Special Health Considerations?
Required Medication and Dosage Amount? (If NONE, write N/A)
Please list any remarks and/or recommended precautions for your child
In the event reasonable attempts to contact myself or the Secondary Emergency Contact have been unsuccessful, I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
I accept the terms of this medical authorization.
WAIVER FOR PARTICIPANT/PARENT
In consideration of accepting my and/or my child's registration, I, on behalf of said group(s) release any and all rights and claims for damages we may have against the City of West Carrollton Parks and Recreation Department and its representatives, successors and assigns for any and all injuries suffered by myself and any guest of said group(s). I do hereby grant and give these groups the right to use a group photograph or image with or without names, both singly and in conjunction with other persons or objects for any and all purposes including, but not limited to private or public presentations, advertising, publicity and promotion relating thereto. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold the City of West Carrollton Parks and Recreation Department harmless of and from any and all liability of whatever nature which may arise out of result from such uses. For the consideration stated above, I further agree that in the event any person of said group(s) repudiates or attempts to repudiate such release, I will personally indemnify and save harmless the City of West Carrollton Parks and Recreation Department, its successors and assigns, for any and all loss and damage occasioned thereby.
I accept the terms of the waiver
$12 Per Child
2% online service fee
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