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2. Program Name
4. Name*
5. Age*
6. Date of Birth*
   Date of Birth
8. Phone Number*
9. Work Phone Number
11. Home Address*
13. City*
14. State*
15. Zip Code*
19. Emergency Contact Information
21. First Name
22. Last Name
24. Address
26. City
27. State
28. Zip Code
30. Email Address
32. Phone Number
33. Alternative Number
37. RELEASE AND WAIVER OF LIABILITY
    I recognize, because of the nature of the activities in which I will be engaged, an injury may be sustained. In the event of such an injury, if I or another guardian cannot be contacted, I give my permission to the attending physician to render treatment as would be customary and I further agree to pay the usual charge for such treatment. For and in consideration of the above-named person participating in the East Chicago Parks and Recreation Program where I participate in a variety of activities at the different Park and Recreation sites, field trips, or events, will remain on the premises until picked up by a family member or emergency contact , if applicable. I hereby release, discharge, waive and relinquish any and all actions or causes of action for personal injury, property damage or wrongful death occurring to myself arising as a result of being at the premises, engaging in any of the activities, engaging on field trip, event, or the transportation to any activities sponsored by the Parks and Recreation Department, whenever or however the same may occur and I also agree for myself, my estate, or my heirs that under no circumstances will I or my heirs, executors, administrators and or assigns prosecute or present any claim for personal injury, property damage, or wrongful death against the City of East Chicago or the East Chicago Parks and Recreation Department or any of the officers, agents, employees, directors, for any cause of action, whether the same shall arise by the negligence of any of those persons or otherwise. I also understand and agree that I may be photographed and/or videotaped for publicity purposes.
39. I have read and voluntarily signed this Release and Waiver of Liability and my signature is an indication that I am in full agreement with the Releases and Waiver of Liability contained in this document and have full knowledge of its significance.
41. Digital Signiture*

    1. I agree to the above information
42. Date
    Date
44. NO REFUNDS, NO EXCHANGES, CASH OR MONEY ORDERS ONLY. EXACT PAYMENT REQUIRED
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46. 1. Receive an email copy of this form.
47. Email address

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48. Submit

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