Registration and Acknowledgment of Risk Form




Program Name*
Participant's Name*
Street Address and City*
Zip*
Phone*
Work Phone
Email (for updates, etc.)
If the participant is under 18 years old please fill out the information in the area below:
Date of Birth**
Parent's Name**
Grade**
School Attending**
T-Shirt Size
Emergency Contact 1*
Phone*
Emergency Contact 2*
Phone*
Doctor*
Phone*
Dentist*
Phone*
Hospital Preferred*
Phone*
Special Limitations/Conditions/Allergies*
I recognize that the Village of Archbold, any of its co-sponsors including other entities, their employees or agents, assume no responsibility for myself or my child. I will assume all risks that may arise from this participation. I also hereby waive any claims against the Village, its co-sponsors, their departments, officers, employees or agents for any injuries or loss that may arise form this participation. This release includes off-site transportation of program participants to and from Village facilities and related field trips and programmed activities. I acknowledge I retain the right to assert any claims that arise from the gross negligence or gross misconduct of the Village of Archbold or any co-sponsoring entities, their officers, employees or agents.
We would like to help out a child. We have enclosed additional money to be used for the registration of a child in need of assistance.