Summer Camp,
Private Lessons /Agility Waiver

I hereby authorize Paul "Rook" & Suzie Silva, City of Visalia, and Tulare County Fairgrounds to act for me according to their best judgment in any emergency requiring medical attention. With full understanding of the potential risk, I hereby waive and release all responsibility to all parties from any and all liability for injuries, illness or lost property. I have no knowledge of any physical impairment that would affect my participation during the training. By signing below I assume the full risks of participating and confirm that the participant is covered by a personal insurance policy.

 

 

Name:___________________________________ Grade:____ Age:____ DOB:________

 

 

Address:______________________ City:____________ Zip:__________ Camp ____

 

 

Phone: (        )______________ E-mail:___________________ Referred By:__________

 

 

 

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Signature (Parent or Guardian)                                                      Date

 

 

 

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Signature (Participant)                                                                   Date


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