REGISTRATION/ WAIVER OF LIABILITY FOR THE PORTAGE SUMMIT
FIELD & STREAM YOUTH DAY August 5
Participation is limited to the first 40 registrations received. Parents/Guardians must accompany minor children. AGE LIMITED 10-16. Completed applications must be received before July 15 to allow for adequate scheduling.
RELATIONSHIP
PARTICIPANT’S NAME (print) AGE TO UNDERSIGNED
1st
2nd
3rd
4th
5th ______
6th ______
Parent or legal Guardian must read & sign the Indemnification, Release, Waiver and Assumption of Risk Agreement in order for their minor children to participate in this activity.
The undersigned legal parent/guardian, on behalf of themselves and the minor participant(s) named above, waive for themselves, and their executors, administrators, assignees, or heirs, any and all rights and claims for damage, losses, demands, and any other actions whatsoever they may have or which may arise against the Portage-Summit Field and Stream Club, the Ohio Division of Wildlife, and any and all staff and volunteers of the Portage-Summit Field and Stream including but not limited to any and all losses, damages, injuries or illnesses suffered by the Minor participant(s), their Parents or Guardians, persons related, connected with, or attending any adult or youth shooting program.
The undersigned legal parent/guardian, on behalf of themselves, the Minor participant(s), and their executors, administrators, assignees, or heirs, hereby expressly indemnify, release, and discharge the Portage-Summit Field and Stream Club and any and all staff and volunteers of the Portage-Summit Field and Stream from any and all such claims.
The undersigned legal parent/guardian, on behalf of themselves and the Minor participant(s) hereby expressly assume the risk of entering the premises of the Portage-Summit Field and Stream Club and of taking part in activities which include, but are not limited to, the discharge of firearms, bows, and air guns firing live ammunition, arrows, and other projectiles.
The undersigned legal parent/guardian, on behalf of the Minor participant(s), consent to the taking and use of any photographs or video for the purpose of promotion, publicity, and news coverage of this event and the Portage-Summit Field and Stream Club in general.
Parent/Guardian’s signature (if sponsoring a minor) ______
STREET CITY STATE ZIP PHONE
Mail or email completed form to:
Portage-Summit Field and Stream
1204 Industry Rd.
Atwater, OH 44201