Personal Information - Parent/Guardians

Primary Parent/Guardian

First Name

Last Name

Primary Phone

Country

(###)

###

####

Secondary Phone

Country

(###)

###

####

Emergency Contact *

First Name

Last Name

Primary Phone *

Country

(###)

###

####

Participant Name *

Full Name

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

Enter the date of birth of the Participant.

MM

DD

YYYY

I give consent for Bartley Skills Development Program to take photographs, videotapes, or make digital recordings of myself/my child. I hereby acknowledge that Bartley Skills Development Program will use program footage, including still photographs and video images for promotional purposes only. *

Yes

No

Waiver on Activities *

I agree that as a parent/guardian of a child/participant who is registered in the Bartley Skills Development Program, I/my child will participate in activities that may be physically challenging. I am aware of the risks and hazards associated with this camp. I agree that Bartley Skills Development Program, its trustees, officers, directors, employees, agents, and independent contractors, shall not be liable for any injury to myself/child or any loss/damage to my personal/child’s property arising from, or in any way resulting from my own/my child’s participation in these activities.

I do