Student Activity Liability Release Form
Please complete this form to acknowledge and release liability for participation in the specified student activity.
Student Full Name
*
First Name
Last Name
Student Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School Name
*
Grade or Class
*
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Relationship to Student
*
Please Select
Mother
Father
Legal Guardian
Other Relative
Other (please specify)
Parent/Guardian Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Full Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Activity Name and Date
*
Parent/Guardian Signature
*
Submit
Submit
Should be Empty: