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The Fun-Set Social and Charity Club

Medical Information and Liability Release

Beau First Name

Last Name

Date of Birth

Mom/Guardian's First Name

Mom/Guardian's Last Name

Mom's/Guardian's Work

Mom's/Guardian's Home

Mom's/Guardian's Cell

Dad's First Name

Dad's Last Name

Dad's Work

Dad's Home

Dad's Cell

Any Health Allergies' or Physical Conditions FSSCC Should be Aware of:

I, , the undersigned parent or legal guardian, do hereby release The Fun Set Social and Charity Club, and its Members from any and all liability which might result from any personal injury claims or cause of action which might result directly or indirectly from my minor teen's participation in any activity which may be conducted under the supervision of the Fun Set Social and Charity Cllub.

Enter Name

Parent/Guardian Signature - Please use Finger or Stylus

Print Name

Relationship to Minor

Select a date

Submitting takes you to the Emergency Contact

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