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Register for Skateboard program for youth

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Parent/Responsible adult Name*
Kid's Name*
MM slash DD slash YYYY
May we ask you about your ethnicity? (This is information is very important in our grant reporting)*
I have read*
I , as an individual or as a parent/guardian of the participant named herein, understand and acknowledge that participation in BCI programs may expose me or the above named participant to activity-related risks and risk of accidental injury including death, damages or loss. I understand that although precautions are taken by BCI, I or the above named participant are responsible for our own safety. I am aware that there are certain risks involved when I or the above named participant participate in BCI programs and knowingly assume all risks and hereby collectively and individually release from responsibility and agree to indemnify and hold harmless the BCI, its officers, agents, board of directors, representatives, employees, independent contractors, volunteers and assigns from all rights, claims, demands, and injuries, including death, damages or loss of any kind, known and unknown, which I or the above participant may sustain as a result of participating in any and all activities connected with or associated with such BCI programs. I accept my responsibility that I and the above named participant have no physical or psychological condition that would prohibit me or the above named participant from participation in BCI programs. I hereby authorize the BCI to act for me or the above named participant according to their best judgment in any emergency requiring medical attention. I do hereby release and grant permission for the BCI to use any photos of me or the above named participant for promotion and advertisement purposes without remuneration. I have read and do fully understand all the above provisions.

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