Friday Fun Day (Grades 4-5) January 30th

Parent Name: *

Child Name: *

Email: *

Phone: *

Authorized Pickup List: *

Child Age: *

Home Address: *

BY SIGNING BELOW I AM DESIRING TO HAVE MY MINOR CHILD PARTICIPATE IN THIS PROGRAM OFFERED AND SPONSORED BY THE LITCHFIELD COMMUNITY CENTER AND WITH FULL UNDERSTANDING OF THE GUIDELINES FOR PARTICIPATION HEREBY AGREE TO HOLD HARMLESS THE LITCHFIELD COMMUNITY CENTER, IT’S OPERATING ORGANIZATION, OFFICERS, AGENTS, EMPLOYEES, VOLUNTEERS, FROM AND LOSS, COSTS, EXPENSES, INJURIES OR PROPERTY DAMAGE AND/OR LIABILITY WHATSOEVER, IN KIND OR NATURE WHICH MAY ARISE FROM PARTICIPATION. I ALSO AGREE THAT MY OWN MEDICAL AND OR DISABILITY INSURANCE WILL BE USED IN THE EVENT OF AN ACCIDENT OR INJURY, AND THAT IF I HAVE NO SUCH INSURANCE I WILL BE DIRECTLY RESPONSIBLE FOR ANY MEDICAL COSTS WHATSOEVER. I ALSO AGREE THAT ANY PICTURES TAKEN OF MY CHILD WHILE ATTENDING THE EVENTS MAY BE USED FOR FUTURE PROMOTION OF THE LITCHFIELD COMMUNITY CENTER.: *