KINERGY DROP-IN WAIVER

Participant's Name *

First Name

Last Name

Participant's Phone

(###)

###

####

Parent Name (for Minor use only)

First Name

Last Name

Parent Phone (for Minor use only)

(###)

###

####

Participant's Date of Birth *

MM

DD

YYYY

Checkbox *

By checking the box below, you agree to waive all liability and acknowledge that you are participating in all physical and non-physical activities at your own risk. If you are checking this box for a minor under the age of 18, you assume guardianship, any risks, and responsibility for this individual.

I AGREE

Activity Date *

MM

DD

YYYY