Advanced Strategies Adventures, Inc.

 

7703 Kirkville Rd. Kirkville, NY 13082

 

(315) 656-9050

 

Liability Release Form

 

 

Program:____________________________Date:_____________________________

Blanket Form:_________________________________________________________

Participant:____________________________________________________________

Participant Guardian/Responsible Party:_____________________________________

Address:_________________________________________________

________________________________________________________

Phone:__________________________ Alternate Phone:_________________________

Emergency Contact:_______________ Emergency Phone:________________________

Date of Birth:_________ Disability:__________________ Onset Date:______________

 

 

All Participants/Guardians/Responsible Parties must sign below.

 

By signing below I/we assume all responsibility and risk associated with participation in any activity or program in connection with Advanced Strategies Adventures, Inc. for any injury or misfortune. I also waive and release any other person, sponsor, guide, volunteer, host, landowner, instructor, official in any event from all claims and/or damage/injury incurred in connection with any event. I consent to and authorize the use and reproduction of any and all photgraphs or any other audio/visual material taken of me for promotional material, educational activities, exhibitions or for any other use that may benefit the program.

 

By signing I attest that I understand this statement, or it has been explained to me so that I fully understand the conditions above.

 

Print Name:_______________________________________________________

Participant Signature:_______________________________________________

Guardian/Responsible Party:_______________________Date:______________

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