Trunk or Treat Car Registration

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* 1. Answer the following demographic information.

Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

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* 2. What is the theme of your trunk that you will present at Truck or Treat Oct 30th from 6p-8p

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* 3. Do you plan to supply your own candy for your trunk during Trunk or Treat Oct 30th from 6pm - 8pm

Yes

No

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* 4. Please read and sign your name below if you agree with the following:

RELEASE AND WAIVER OF ANY AND ALL CLAIMS AS A RESULT OF PARTICIPATION IN ACTIVITIESOR SUPPORT COUNSELING OR INJURIES OR PROPERTY LOSS OR DEATH: The undersigned hereby attests and acknowledges that he/she is entering upon property owned and or leased by The Southeast Youth Council, Inc. with full knowledge of the potential risks, dangers and possibility of injury that may arise out of operation and activities of The Southeast Youth Council, Inc. I/we further acknowledge that The Southeast Youth Council, Inc., its employed staff, its volunteer staff, its officers and/or it directors may offer several forms of support counseling or activities which may result in injury or loss of property. I/we agree that The Southeast Youth Council, Inc. will not be held responsible for those injuries or property losses incurred while engaged in activities and/or support counseling offered. I/we further agree to indemnify and hold The Southeast Youth Council, Inc., its employed staff, its volunteer staff, its officers and or its director harmless from any and all liability including claims asserted by third parties for any care rendered to the undersigned.