Section 1 of 5
Section 2 of 5

In the event the parents/guardians cannot be reached: the school will call the people listed below. People listed should be individuals who can: 1) pick up your child from our program; 2) give permission to administer health care; 3) give advice about caring for your child.

Please note all the below contacts are subject to identification checks; please be prepared with ID. Your child WILL NOT be released, to anyone not included in the above listing, without a written statement from the custodial parent received before the time of pick up. Children may not sign themselves out of the program.

If any of the contact information changes, please notify City of Moraine staff immediately, 937-535-1060.

Section 3 of 5
Section 4 of 5
Section 5 of 5

As the parent/guardian, I give permission for my child to participate in this Moraine Parks and Recreation Program. I give permission for my child to participate in all program related activities.

I hereby authorize the City of Moraine and/or authorized representative or emergency medical personnel to furnish emergency services and/or secure emergency medical treatment (transport to a hospital and admission) for my child. I agree to be financially or otherwise responsible for this service. I release, discharge and agree to hold harmless the City of Moraine, its officers, employees, agents, and all others who could be held liable from any and all claims which in any manner arise from or as a direct result of this service.

I assume responsibility for any injury, loss or damage resulting directly or indirectly from participation in the above listed programs and will not institute any negligence or other claim against The City of Moraine, its agents, or any other person who could be held liable either in their individual or official capacities. I agree to hold the above named parties harmless from any liability for any personal or property injury. I hereby fully release and discharge The City of Moraine from any negligence or other claim for liability, loss or damage. I also agree to indemnify The City of Moraine or its agents for any personal injury or property claim resulting from my child's actions.

I understand that these activities are performed under this specific agreement. I have read and understand the foregoing and voluntarily sign this waiver with full knowledge of its significance.
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