Event Waiver Form
Event Name
Event Starting Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Event Ending Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Personal & Contact Information
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Name
First Name
Last Name
Age
Example: 23
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
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If there is any health conditions, please explain
Astma, diabetes, allergies, medications
Is there any activity restrictions?
Yes
No
If yes, Please explain
Health Insurance
Â
Do you have any health insurance?
Yes
No
Insurance Company
Policy Number
Policy Holder
Release
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I, undersigned, agree with the following statements
Medical Release: Between starting and ending of the event, as deemed necessary,I authorize activity holder to select the hospital or dentist for hospitalization, to secure proper treatment, and/or order an injection, anesthesia, or surgery, for the person specified above.
Liability Release: Even with the best of planning and precaution, unforeseen events can occur. By signing this form, I agree to assume and accept all risks and hazards inherent in the activities. They also agree not to hold activity holder or its employees or volunteer assistants liable for damages, losses, or injuries to the person or property undersigned.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: