Name: _________________________________________

Address: _______________________________________

Age: ______ Birth Date: _______________________

School: ________________________________________

In case of emergency notify:

Phone: _________________________________________

I certify that my child is physically able to participate in this event. I acknowledge and agree that the organizers and sponsors DO NOT provide direct supervision of my child and that the responsibility is upon me or my designee. I recognize that my child will voluntarily be engaging in activities which involve risk of injury, scarring, disability, or death. Such injury may result not only from my child’s action, inaction, and/or negligence, but also the actions of others, the nature of the event, the conditions of the premises, or the equipment used. There may also be other risks not known or reasonably foreseeable at the time. I assume all of the foregoing risks and accept personal responsibility for any damages following injuries, disabilities, or death. Further, in consideration of acceptance of my child’s entry into the event, I, on behalf of myself, heirs, administrators, and assigns, and those of my child’s, do hereby release, waive, and discharge the organizers of the event, including but not limited to, the Blair County Respiratory Disease Society, its employees, agents, board members, advisors, insurers, and the event sponsors, as well as the Altoona Area School District, from any and all claims, damages, demands, and actions whatsoever in any manner arising from my child’s participation in this event.

____________________________________

Signature of Parent/Guardian Date

I acknowledge that photographs, videos, and/or digital images may be taken throughout the event. I authorize my child’s image to be taken and used for informational and promotional purposes without compensation to me or my child.

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Signature of Parent/Guardian Date