NEW YORK STATE MOOSE ASSOCIATION

Release Form

Event _______________________________      Date _______________________________

Participant (Please print)______________________________________________________ 

Date of Birth ______/_____/_________                 (X) M____ F____

Sponsoring Lodge/Chapter ______________________________________ #___________ 

Participants Phone (___) ______________________

In consideration of the acceptance of my son /daughter in the above stated event, I hereby waive, release, and discharge any and all claims for damages, death, personal injury, or property damage which I may have, or which subsequently occur to me as a result of my participation in this event. This release is intended to discharge MOOSE INTERNATIONAL INCORPORATED, and any State or Provincial Association and/or any sponsoring Lodge(s), their Representative Agent(s), and employee(s)  from and against any and all liability arising out of, or connected in any way with my participation in this event, even though liability may arise out of negligence or carelessness on the part of the person(s) or entity(s) mentioned above. The terms hereof shall serve as a release and assumption of risks for my heirs, executors, successors, administrators, and assigns in exchange for my participation in this event. I, the undersigned, acknowledge that I am the parent / legal guardian of the participant and that my son / daughter is under no physical disability that would prohibit his / her participation in this event. My signature also indicates that should it become necessary for my son / daughter to be transported to and from this event, that my permission is granted. I, the undersigned, attest and affirm that I have read this document and that the statements for the above are true, and agreed to.

Parent / Legal Guardian 

Signature ________________________________      __________________________________

                              (Signature)                                               (Print)

Address ______________________________________________________________________ 

City _________________________________________ State _____________ Zip ___________

Date _____________________________                         Phone (____)______________________

** Birth Certificates will be required at registration or send a copy with application.

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