FIRST NAME _______________________   LAST NAME _______________________________

AGE _________________    MALE _____   FEMALE _________

ADDRESS _________________________________________________________

CITY ___________________________   STATE ______    ZIP CODE ________________

PHONE _____________________    OCCUPATION ___________________________

MEDICAL PROBLEMS / ALLERGIES ________________________________________

CONTACT IN CASE OF EMERGENCY ____________________________________

As a participant in the program, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries or loss which I may sustain as a result of participating in any and all activities with or associated with such program.

I agree to waive and relinquish all claims I may have as a result of particiapating in the event against the City and its officers, agents, servants and employees.

I do hereby fully release and discharge the City and its officers, agents, servants and employees from any claims from injuries, damage or loss which I may have or which may accure to be arising out of, connected with, or in any way associated with the activities of the event.

I futher agree to idemnify and hold harmless and defend the City and its officers, agents, servants and employees from any claims from injuries, damage or loss which I may have or which may accure to be arising out of, connected with, or in any way associated with the activities of the event.

I have read and fully understand the above Event Details, Waiver and Release of all claims and permission to Secure Treatment.

Name (please print) __________________________________________________________

Signature _______________________________________________________________

                                           (Parent / Guardian if under 18)

Date __________________________