Public Safety Program Waiver Form

Public Safety Program Waiver Form
Please read and complete this waiver form before participating in the Public Safety Program.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contact Name
First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
I hereby acknowledge that participation in the Public Safety Program involves inherent risks. I voluntarily assume all risks and responsibilities associated with my participation. I release and hold harmless the organizers, sponsors, and volunteers from any liability for injury, loss, or damage that may occur.
Signature
Clear
Date of Signature
MonthDayYear
Date
Should be Empty: