Child Activity Registration Form

"*" indicates required fields

First Name*

Last Name*

Date of Birth*

Email*

School*

Address*

Mother’s/Guardian Name*

Home Phone*

Mobile*

Work Phone*

Father’s/Guardian Name*

Home Phone*

Mobile*

Work Phone*

** The following people are authorised to pick up my child from our center:

Name

Relation

Phone

Name

Relation

Phone

Name

Relation

Phone

My child’s participation in the activity(s) selected is voluntary. I understand that the selected activities may involve accidental injury and hereby voluntarily assume such risks. Knowing these risks, I want my child to participate in this activity(s). I (on behalf of my child) hereby assume the risk, and hereby waive, release, discharge Lough Allen Adventure, its officers, employees, activity instructors and assistants, and all officers and employees where said activity(s) will take place, for any and all claims for damages for personal injuries, or claims for damages to property, which my child or my child’s heirs, assigns, executors or administrators may have or which may accrue to my child’s participation in this activity. I have read the above and understand that important legal rights are being waived.

Does the child have any allergies or medical condition?*

Yes

Explain Condition

Please indicate the child's level of water confidence and swim ability level below*

Any additional information can be entered below

Signature*