I here by grant permission for the above named individual to participate in the Trudeau Center's Recreation Program.

I represent and warrant to you that the participant is physically and mentally able to participate in registered programs.

On behalf of the participant and or myself. I hereby release you from any liability arising out of your permitting the applicant to participate in the program and I agree to defend and hold harmless against any claims of liabilities asserted against you at any time by or on behalf of the participant by reason such participation of any other matters or things to which this application appertains.

In permitting the applicant to participate, I am specifically granting irrevocable permission to you to use the likeness, voice, and words of the participant in television, radio, films, newspapers, magazines, and any other media, and in any form not heretofore described, for the purpose of advertising or communicating the purposes and activities of the program.

If I am not personally present, so as to be consulted in case necessity, you are authorized on my behalf and at my account to take such measures and arrange for such medical and hospital treatment as you may deem advisable for the health and well being of the participant.

Parent / Guardian Signature: _________________________________Date:_________________

Parent / Guardian: ___________________________________ Phone:_________________

Work:__________________