PARENTAL CONSENT FORM & INDEMNITY AGREEMENT

Student/Participant Name________________________________________________________

Date of Birth______________________________________

Parent/Guardian Name__________________________________________________________

Home Address_________________________________________________________________

Home Phone___________________________________

Event:  Video Game Competition

Date of Event: MAY 1, 2010   @ 11:00 am check-in

Location:  Carr Square Recreation Center

                1629 Biddle Ave.  St. Louis, MO 63106

Student Cost: $10.00 to participate

I, _________________________________, grant permission for ________________________

Parent or Guardian Name                                                                                                                        Child Name

to participate in the above named activity and I warrant that my child is in good health. In

consideration of my child’s participation, I agree to indemnify Helping Hands Helping Others from any claims or lawsuits brought against Helping Hands Helping Others

by myself, my child or others, that arises out of any behavior by my child at the event/activity

described above.

In the event of any emergency, if you are unable to reach me

at the above numbers, contact______________________________ ______________________

                                                                                                Name                                                       Phone Number

 

As Parent or Guardian, I agree to all of the above stated considerations and conditions.

______________________________________________________ _____________________

Signature                                                                                                                                 Date

Print form and submit with parent's signature at Check-in to the competition.  Forms will be available at check-in.

Back to Rules

"Play for a Cause"

VIDEO GAME

COMPETITION!

H

elping