Child's Name *

First Name

Last Name

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

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Parent's Name

First Name

Last Name

Address (if different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Phone (if different)

(###)

###

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I Agree To The Event Terms & Conditions *

I give the Future Nurses Program/Teberah Alexander/Nurse T my permission to use the photographs/video described for any legal use, including but not limited to: publicity, copyright purposes, illustration, social media, advertising, and/or web content. Furthermore, I understand that no royalty, fee or other compensation shall become payable to me by reason of such use. “I am the parent or legal guardian of the Participant(s)/child listed. I have read this document, and I am signing it freely. I understand the legal consequences of signing this document, including (a) releasing the Future Nurses Program/Teberah Alexander/Nurse T/ Nurse Who Care/Renaissance High School from all liability on my and the Participant’s behalf, (b) waiving my and the Participants’ right to sue the above in A (c) and assuming all risks of Participant’s participation in this Activity, including travel to and from the Activity (including air travel) or any events incidental to this Activity. I allow the Participant to participate in this Activity. I understand that I am responsible for the obligations and acts of the Participant as described in this document. I agree to be bound by the terms of this document.

Yes