Please Print) (One Form Per Family

2014-2015 NRDA Buddy Form

(Please Print) (One form per family)

Student #1 Name: ______Birthday: ______

Parent/Guardian’s Name(s): ______

Phone #: ______Email: ______

Special Needs/Allergies: ______

I hereby certify that my child(ren) is in normal health and capable of participating safely in NRDA programs. Participation in this program is at my own risk and hereby releases NRDA or its instructors from any and all claims for damages and injuries which may be sustained while participating in any and all activities connected with NRDA.

Parent Signature: ______Date: ______

I give permission to NRDA to use my child(ren)’s photograph on our website or in any advertising or news coverage of our events.

Parent Signature: ______Date: ______