Activity Participation Form

In order to participate, you must complete and return this form.

Activity Information Description of Activity:
Activity Age Group:
Date of Activity:

Participant Information Participant First Name:
Participant Last Name:
Address:
Address 2:
City:
State:
Zip:
Email:
Parent or Guardian's First Name:
Parent or Guardian's Last Name:
Emergency Contact Phone Number:

Medical and Insurance Information Is the participant covered by personal/family medical insurance? Yes No

If yes, please list the name of insurer and group or policy number:
Is the participant currently taking any medication, have any allergies or medical conditions? Yes No

If yes, please explain:

Agreement

By clicking below, the participant (or parent / guardian if participant is a minor) acknowledges and accepts the risks of physical injury associated with participation in the activity described above. Except for gross negligence on the part of the sponsor, the participant (or parent / guardian) accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further, the participant (or parent / guardian) promises to hold harmless the sponsoring organization and its representatives for any injury related to the activity.

If a dispute over this agreement or any claim for damages arises, the participant (or parent / guardian) agrees to resolve the matter through a mutually acceptable arbitration process.

Do you agree with the terms and conditions?

Yes, I agree.

Parent or Guardian's Full Name:
Date: