LOVE OUR LIVES & LOUISE RUSSO W.A.V.E. Back to School Registration FRIDAY AUGUST 17TH 2018 Please fill out the form below including date, location, numbers in audience, theme and topic request. Participant’s Name * Date of Birth * Full Address * Parent’s Name * Home Phone * Cell Phone Number * Email * Emergency Contact Name Emergency Contact Number * Email * Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe. Informed Consent and Acknowledgement * I Accept I hereby give my approval for my child’s participation in any and all activities prepared by Love Our Lives during the Back to School Workshop. In exchange for the acceptance of said child’s candidacy by Love Our Lives, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Love Our Lives and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Love Our Lives and Louise Russo W.A.V.E. including all counselors and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the camp. Medical Release and Authorization * I acceptI do not accept I grant permission to Love Our Lives to use my child’s/children’s photographs and/or videos for use in Love Our Lives publications including videos, recruiting brochures, newsletters, magazines, website images social media or other electronic forms of media. All images belong to Love Our Lives for promotion purposes. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown. I waive any right to royalties or other compensation arising from or related to the use of the image. I have read and I understand the contents, meaning and impact of this realse. I understand that I am free to address any questions regarding this release by addressing those questions prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. Additional Information Sign Name * BY ACKNOWLEDGING AND REWRITING YOUR NAME ABOVE, YOU AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.