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2. Today's Date*
   Today's Date
4. Child 1
6. Child's First Name*
7. Child's Last Name*
9. Child's Birthdate*
   Child's Birthdate
10. Child's Age*
12. Child 2
14. Child's First Name
15. Child's Last Name
17. Child's Birthdate
    Child's Birthdate
18. Child's Age
20. Child 3
22. Child's First Name
23. Child's Last Name
25. Child's Birthdate
    Child's Birthdate
26. Child's Age
28. Primary Guardian*
30. Home Address*
32. Home Phone
33. Cell Phone*
35. Email Address*
37. Emergency Contact Name (Other than person listed above.)*
39. Relationship to the Child*
40. Emergency Contact Phone Number*
42. Allergies (Food, Medication, Environmental)
44. Special Needs, or anything important the Staff should be aware of:
46. Authorization

    WAIVER FOR PARTICIPANT AND BY PARENT/GUARDIAN:

    In consideration of your accepting me or my child’s entry, I hereby, for myself, my child, my heirs, executors and administrators, waiver and release any and all rights and claims for damages I or my child may have against the City of Vandalia Parks & Recreation Department and its representatives, successors and assigns for any and all injuries suffered by myself or my child on any activity sponsored by these groups.  I do hereby grant and give these groups the right to use my or my child’s photograph or image with or without my or my child’s name, both single and I conjunction with other persons or objects for any and all purposes including, but not limited to, private or public presentations, advertising, publicity and promotion relating thereto.  I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold the City of Vandalia Parks & Recreation Department harmless of and from any and all liability of whatever nature which may arise out of result from such fees.  For the consideration stated above, I further agree that in the event my child repudiates or attempts to repudiate such release, I will personally indemnify and save harmless the City of Vandalia Parks & Recreation Department, its successors and assigns, for any and all loss and damage occasioned thereby:

48. Electronic Signature of Parent/Guardian*
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field