Adult’s Last Name:	Adult’s First Name:
Phone Home:	Day Phone:
Address:
City State Zip:
Participant Name Age/Grade Activity Name  Fee $ Shirt Size                                                                                  Total:
Check # _________(Make payable to City of Chehalis)
I am fully aware of the special dangers and risk inherent in the activity, including physical injury, death, or other consequences that may arise or result directly or indirectly from the activity.  In the event of a serious injury and we are unable to contact a parent or guardian the supervisory staff will seek emergency medical assistance. Being fully informed as to these risks and in consideration of the privilege of participating in the above-described activity, I hereby assume all risk of injury, damage and liability and waive any right of recovery from or to bring suit against the City of Chehalis or the Chehalis School District (if applicable), for any personal injury, death, or other consequences arising out of my voluntary participation in the activity, except for the sole negligence of the City.
Participant Printed Name         Signature of Participant                                   Date
I certify that I am the parent or legal guardian of the participant named above; that I have read and understood the foregoing release; and that I join in the release without reservation, granting full consent and authorization for the above-named person to participate in the activity.
Parent/Guardian Printed Name             Parent/Guardian Signature                   Date

Mail or bring your form and payment to:
City of Chehalis
1321 S. Market Blvd.
Chehalis, WA  98532