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Steps

1. Step One This section is complete This section is incomplete
2. PERMISSION, RELEASE AND HOLD HARMLESS AGREEMENT This section is complete This section is incomplete
3. Permission to Videotape and/or Photograph This section is complete This section is incomplete

Step One

Summer Reading Program Permission/Registration Form
Please complete and submit one form per child.
Date*
Participant Name*
Participant's Age*
Parent/Guardian Name*
Home Address*
City*
State*
Zip Code*
Home Phone*
Work Phone*
Email Address*
Emergency Contact Name*
Emergency Contact Phone*
Program Weeks*
1. Week 1
2. Week 2
3. Week 3
4. Week 4
5. Week 5
6. Week 6
7. Week 7
8. Week 8
Please check each program the participant plans on attending.
Special Needs
Please note any special needs the participant may have.
Signature*
1. By checking this box and typing my name below, I am electronically signing my application.
First Name*
Last Name*
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PERMISSION, RELEASE AND HOLD HARMLESS AGREEMENT

The City of Bisbee Copper Queen Library and its staff will attempt to provide high quality programs in an appropriate environment. Recreation activities, by their very nature, may present circumstances that place the participants at some risk of injury. The potential of injury varies significantly depending on the type of activity and the intensity of involvement. Please make sure that you have inspected the area to be used and that you have determined that this activity will be appropriate for you or your child, as applicable, based upon your particular physical condition, or that of your child. As a condition for allowing your participation, or that of your child, the City of Bisbee will require that you release and hold harmless the City from claims that may arise from this activity.
I assume the responsibility of my/my child’s mental and physical fitness to participate in said program, and agree to abide by all rules and requirements of the program.
The undersigned hereby agrees to assume all of the risks and to accept personal responsibility for any and all injuries and damages that I and my child or ward may sustain as a result from participation in this activity. I hereby release, indemnify, hold harmless and agree not to sue the City of Bisbee, it officers, employees and agents, for all demands, losses or damages, including personal injury and death, caused by or alleged to be caused, in whole or in part, by any actions, omissions or by the negligence of the released parties in connection with this activity. I hereby authorize my child or ward to participate under these same terms and conditions.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, I UNDERSTAND THAT I HAVE GIVEN UP VALUABLE RIGHTS BY SIGNING IT, AND I DO SO VOLUNTARILY.
Relationship to Above Child*
Date*
Signature*
1. By checking this box and typing my name below, I am electronically signing my application.
First Name*
Last Name*
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Permission to Videotape and/or Photograph

Permission to Videotape and/or Photograph
I understand the City of Bisbee may photograph or videotape the events or activity in which I am (or my child) is participating. I give my permission for the City to use photographs or videotape programs. I give my permission with the following understanding: No compensation of any kind will be paid to me (or my child) at this time or in the future for the use of my (or my child’s) likeness.
Are you the legal guardian of above child?*
1. Yes
Are you 18 years of age or older?*
1. Yes
Participant Name*
Signature*
1. By checking this box and typing my name below, I am electronically signing my application.
First Name*
Last Name*

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Summer Reading Registration Packet

Steps

Step One

PERMISSION, RELEASE AND HOLD HARMLESS AGREEMENT

Permission to Videotape and/or Photograph