Kolacky Days - Montgomery, MN

Youth Name *

First Name

Last Name

Youth Preferred Phone

(###)

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Student Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent / Guardian Name - To Be Completed by Parent / Guardian *

By entering my name below, I represent that I as a valid parent/guardian, I am approving this form and agree to the waiver/release on behalf of the minor.

First Name

Last Name

Waiver/Release - To Be Completed by Parent / Guardian *

As the Parent / Guardian, I do hereby give my consent and agree to allow my youth to participate in Montgomery Area Community Club activities. Furthermore, the Community Club members supervising these activities may act in my stead, including medical treatment for my youth. I will not hold Montgomery Area Community Club or its staff fiscally or legally responsible for injuries or damages incurred during these activities and waive all rights to legal redress.

Agree

Don't Agree

Parent / Guardian Phone

(###)

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