Waiver | im-mike-brown

Camp Liability Waiver

To complete registration, please take the time to fill out the information below.

Participant First Name

Participant Last name

Parent/Guardian Full Name

Please specify any health concerns and/or other information we should be aware of for particpant

I declare that the info I've provided is accurate and complete

I hereby acknowledge this release from liability for accidental injury or illness which may be incurred as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program with the medical staff prior to participating.

Emergency Contact Name

Emergency Contact Phone

Parent/Guardian Signature