Community Education Youth Program

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Student name

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Student Email

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Student Grade

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Class Name

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Address

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City

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State

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Zip Code

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Parent/Guardian Name

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Parent/Guardian Email

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Parent/Guardian Phone Number

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Additional Parent/Guardian Name

Additional Parent/Guardian Email

Additional Parent/Guardian Phone number

Today's Date

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Emergency Contact Name

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Emergency Contact Phone

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Form Consent

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I certify that the participant’s present level of physical condition is consistent with demands of active participation in this program. I agree to forever release, discharge, and covenant not to sue the Laurel Public Schools/Laurel Community Education for liability from any and all lost or damage, whether or not caused by negligence, either active or passive, by or on the behalf of the Laurel Schools/ Community Education. I will indemnify and hold the Laurel Public Schools/Laurel Community Education harmless from any and all claims made by others. I assume all the risks and hazards incidental to the conduct Laurel Public Schools/Community Education programs and I do further release, absolve, indemnify, and hold harmless the Laurel Public School/Laurel Community Education the organizers, sponsors, supervisors, volunteers, and officials of any or all of the supervisors appointed by them. I also acknowledge that participants may be photographed, videoed and recorded providing opportunity for Laurel Public Schools/Laurel Community Education promotions.

Signature

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DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent/Guardian Signature

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