CedarRoot Registration: Personal Info/Liability Waiver

Name

First Name

Last Name

Program/Class

Phone

(###)

###

####

Emergency Contact Name

Emergency Contact Phone #

Pertinent Medical Information

Waiver of Liability

I certify that the information provided on this form is true and accurate. I agree that I, or my enrolled child, will adhere to safety instructions and will wear appropriate clothing and safety equipment as directed by the instructors. While I fully understand that some class activities could result in personal injury, I assume the full risk of injury as a result of my or my enrolled child’s participation in any course or activities at or conducted by CedarRoot. This includes injury caused by the negligence of other participants. Myself, my heirs, executors, administrators and assigns forever release CedarRoot, its officers, directors, agents, employees, teachers and landlords from all liability, claims, demands, actions, causes or action, of whatever type or nature, for any injury to me or my enrolled child’s person arising from my enrollment or participation. PLEASE SIGN YOUR NAME (IF OVER 18) OR PARENT/GUARDIAN SIGNATURE FOR A MINOR

Do we have permission to utilize still or motion picture images of the participant in this program or events for outreach purposes, including but not limited to electronic or print materials, or print or broadcast media?

yes