Parent/Guardian Name *

Please enter the information of the parent or guardian

First Name

Last Name

Best contact number *

(###)

###

####

Address of Parent/Guardian *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name *

Please enter the name of the child attending this event.

First Name

Last Name

Name of School or Program *

Please choose the school or program your child is a part of.

Myers Elementary

White County 4-H Program

College Park Elementary

Child's Date of Birth *

MM

DD

YYYY

Photo Release Terms *

I understand that while participating in this kind of activity or related activities participants will be photographed and filmed. I understand and agree that the photograph(s) and video images may be used in whole or in part, at any time, in composite or distorted form, in color or otherwise and may be displayed through any medium including, but not limited to printed medium, video or on the internet. By signing this waiver I authorize any initial and any subsequent disclosure or publication of the photograph(s) at any time. FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION) This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law. Do you agree with the conditions outlined in our Photo Release?

I agree to the terms of the photo release.