Bristow Moms and Kids (B-MAK)

Member Information and Liability Form

All members must have a signed liability form on file with B-MAK before attending any club activities.

NAME:

ADDRESS:

TELEPHONE: NEIGHBORHOOD:

HUSBAND’SNAME:MOM’SBIRTHDAY:

EMAIL:

CHILDREN’S NAMES AND BIRTHDATES:

Do you work outside the home or do volunteer work? If so, what do you do?

Please list any hobbies or special interests:

How did you hear about us?

The information provided above is solely for the use of Bristow Moms and Kids. This information will be listed in our membership directory and will not be released to any party outside of B-MAK.

I, the undersigned, understand that my participation and the participation of any members of my family in any Bristow Moms and Kids activity or program is completely voluntary, and we hereby give permission for myself and my family to join in those activities or programs.

I understand that as the member I will be bringing my children to Bristow Momsand Kids activities and playgroups, not other caregivers (i.e., babysitters or nannies).

I understand that I am joining a social club that does not provide any insurance coverage for any activities or programs that I, my child(ren) or my family may participate.

I agree to assume full responsibility for my actions, including intentional and negligent, as well as the actions of my child(ren) and family in activities in which I or they will participate as a member and hold this social club harmless.

Additionally, I and my family shall hold harmless Bristow Moms and Kids social club, the Bristow Moms and Kids corporation, any club volunteers or representatives, paid or unpaid, all officers and directors of this club while acting in their official capacity for this club, and/or the providers of any activity or program location and/or materials from any liability and/or responsibility for any accident, illness or injury that occurs during or as a result of any function or program.

I accept that the final responsibility for my safety and that of my family rests with me.

DATESIGNATURE