The Salvation Army
445 Madison Street, Waukesha, WI53188
Tel: 269-547-7367
Permission/Waiver Form: 2011 Youth Programs
Salvation Army CampCorn Maze
October 14, 2011 4:30 p.m. - 8:00 p.m.
Name of Child/Participant (please print): ______
Parent(s) and/or legal guardian(s) of child participant:______
Address:______
StreetCityState Zip
Home Phone( )______Work Phone( )______
Age of Child: ______Birth Date: ______Academic Grade: ______
Activities, Special Events and Field Trips: I understand that the child named above will be participating in the Salvation Army Corn Maze Trip to Salvation Army Camp, East Troy, WI Friday, October 14, 2011. We will leave SA at 5:00p.m. arriving at camp 5:30 p.m. At that time we will participate in the Corn Maze, activities, and a simple dinner. We will head back to Waukesha about 7:30 p.m. arriving here at 8:00 p.m. We will be transported in Salvation Army vehicles.
In signing this Permission/Waiver Form, I do understand that there may be certain risks associated with the activity above. I declare that the child named above is capable of withstanding both the physical and mental demands of the activities discussed above. I freely assume all such risks, both know and unknown and assume full responsibility for participating.
Other Information: Other information leaders should know about the child:
For Use if the Participant is a Minor
I represent that I am the parent/guardian of ______, who is under 18 years of age. I have read the above Permission/Waiver Form and am fully aware with the contents of it.
I give permission for the child named above to participate in the above activities for The Salvation Army.
______
Signature of Parent or Legal Guardian DatePrint Name of Parent or Legal Guardian
______
Witness Signature Date
Consent to Publication by The Salvation Army
I certify that I ______am at least 18 years of age, my birth date being ______, 19______, and having the right to contract my own name to the extent herein set forth.
I hereby irrevocably grant to The Salvation Army, its successors and assigns, its agents and those by whom it is commissioned, the absolute, unrestricted and unlimited license, right, permission and consent to use and reuse, disseminate, copyright, print, reproduce, publish and republish, for any and all trade purposes or commercial or other advertising or public purposes, and in any and all advertising, publicity, display, publication or media, my name, signature and likeness, and any portraits, pictures, photographic prints or other representations of me, or in which I may appear, or any reproductions or sketches thereof or parts thereof, photographic or otherwise, with such additions, deletions, alterations or changes therein as you in your discretion may make, either separately or together with my name or a fictitious name, or the name of another person, with or with or without any statements or testimonials made by me, or authorized by me which you may, in your discretion, prepare for use in connection therewith. I warrant that I have not limited or restricted the use of my name or photograph to the use of any organization or person. I hereby grant unrestricted use of audio tracks or text by The Salvation Army for such purposes as The Salvation Army may deem appropriate.
I hereby release and discharge The Salvation Army, its successors, assigns and agents from any and all claims and demands arising out of or in connection with the use of any of the foregoing, including any claims for defamation, invasion of privacy or violation of any statutory right.
Authorization relating to a minor or individual under local guardianship
I hereby certify that I am the (parent) or (legal guardian) of a minor child or dependent,
______and have executed this release on (his) or (her) behalf.
Print Name of Minor
Name (Print) ______Signature:______
Address______City______State______Zip______
Witness to execution of release
Date: ______
Name (Print) ______Signature:______
Address______City______State______Zip______