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enrollment form
PLEASE FILL OUT THIS FORM AND MAIL IT TO 3476 SMITH AVE BIGGS, CA 95917
FAMILY INFORMATION
PHONE #
NAME OF CHILD YOUR ENROLLING
ADDRESS
CITY
STATE
ZIP
E-MAIL ADDRESS
DOB
AGE
SEX M F
SHIRT SIZE S M L XL
DIAGNOSIS
DOCTOR NAME
PHONE#
ADDRESS
CITY
STATE
ZIP
FAX #
MOTHER'S FULL NAME
FATHER'S FULL NAME
SIBLING 1
AGE
SEX: M F
SIBLING 2
AGE
SEX: M F
SIBLING 3
AGE
SEX: M F
SIBLING 4
AGE
SEX: M F
SIBLING 5
AGE
SEX: M F
YOUR HEALTH CARE PROVIDER:
NAME:PHONE:
ADDRESS:
INSURANCE INFORMATION( FOR EMERGENCY ONLY)
CARRIER:POLICY #
MEMBERS NAME
SS#
NOTE: ALL OF THE ABOVE INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL
RELEASE OF LIABILITY
ON BEHALF OF OURSELVES AND THE FOLLOWING CHILDREN1.
2.
3.
4.
5.
I/WE AGREE TO RELEASE MAX'S MIRACLES INC., AND THE MIRACLE RANCH FROM ANY AND ALL CLAIMS FOR PERSONAL INJURY AND/OR PROPERTY DAMAGE, LIABILITIES, OBLIGATIONS, PREMISES LIABILITY, RIGHTS, DEMANDS, ACTIONS, DUTIES, CONTROVERSIES, PROMISES, DEBTS, LIENS, CAUSES OF ACTION, LOSSES, COSTS AND EXPENSES OF ANY KIND AND EVERY KIND, NATURE, AND CHARACTER, KNOWN OR UNKNOWN AND DEMANDS OF EVERY KIND AND NATURE, KNOWN AND UNKNOWN, INCLUDING, BUT NOT LIMITED TO, ATTORNEYS FEES AND COSTS, ARISING FROM OR RELATED TO PARTICIPATION I THE MAX'S MIRACLES EVENTS. THIS INCLUDES, BUT IS NOT LIMITED TO, ALL LIABILITY FOR DAMAGES AND INJURIES TO BOTH PERSONS AND PROPERTY BROUGHT ABOUT, CAUSED BY OR STEMMING FROM, THE ACTIVE OR PASSIVE NEGLIGENCE OF ANY OR ALL OF THE RELEASED PARTIES.
DATED:
MOTHER'S NAME (PRINT)
MOTHER'S SIGNATURE
DATED:
FATHER'S NAME (PRINT)
FATHER'S SIGNATURE
MEDIA PHOTO AND VIDEO RELEASE
I, ACKNOWLEDGE AND UNDERSTAND THERE IS A POSSIBILITY THAT EITHER LOCAL OR NATIONAL TELEVISION VIDEOTAPING AND /OR LOCAL OR NATIONAL PHOTO DOCUMENTATION MAY BE OCCURRING DURING MAX'S MIRACLES EVENTS. WE REQUEST THE SIGNATURE OF BOTH PARENTS IF THEY'RE TWO PARENTS/LEGAL GUARDIANS.
(PARENT/GUARDIAN SIGNATURE) (DATE)
(PARENT/GUARDIAN SIGNATURE) (DATE)
AS PARENT/GUARDIAN OF:CHILDREN'S NAME(S)
I DO I DO NOT
(PARENT/GUARDIAN NAME)
GRANT PERMISSION TO BE VIDEOTAPED/PHOTOGRAPHED, AND RELEASE ALL RIGHT TO MAX'S MIRACLES, INC. , FOR THE PURPOSE OF FUNDRAISING, MARKETING, CAUSING AWARENESS AND FOR SLIDESHOWS.
(PARENT/GUARDIAN SIGNATURE) (DATE)
(PARENT/GUARDIAN SIGNATURE) (DATE)
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maxamillian |
Latest page update: made by maxamillian
, Aug 24 2008, 8:24 PM EDT
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