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Placer Enrichment Release Form
Child's Name
Date of Birth
Second Child's Name (if applicable)
Date of Birth
Third Child's Name (if applicable)
Date of Birth
Parent's Name
Phone Number
Second Parent's Name
Phone Number
Emergency Contact
Phone Number
Does your child have any medical conditions?
MEDICAL EMERGENCIES: I give permission to Placer Enrichment, its owner and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian.
ABILITY TO ENGAGE IN ACTIVITIES AND ASSUMPTION OF THE RISK: I acknowledge that risks from participation in class activities at Placer Enrichment exist and that I allow my child to attend classes knowing these risks and their possible consequences including personal injury. WAIVER AND RELEASE OF LIABILITY: As a parent or guardian of my child, I agree that I will not hold Placer Enrichment liable for any personal injury, property damage or loss of insurance. I agree to release and hold harmless Placer Enrichment and owner, Melissa Stewart from all liability incurred as a result of my child’s participation in class and that these terms serve as a release for employees, volunteers and property owners.
I give Placer Enrichment permission to take photo's/video's of above applicant(s). These may be used for promotion, yearbook, etc.
Your Signature
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