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* 1. Parent/Legal Guardian First Name, Last Name, Phone Number, Address

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* 2. Participant's Name

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* 3. Participant's Birth Date

Date

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* 4. Participant's Gender

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* 5. Participant's School and Grade

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* 6. Participant's Email

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* 7. Participant's Phone Number

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* 8. Photo Release and Waiver & Release of Liability

PHOTO RELEASE: I agree, as a participant, parent or guardian of any paid or free event, class, activity, or program to grant full permission to  LATI/SCYTF to use our name(s) and any photographs, videographs, motion pictures, or recordings for any publicity and promotion purposes without obligation or liability to me.

WAIVER & RELEASE OF LIABILITY: The undersigned, in consideration of participation in this program, agrees to indemnify and hold LATI/ SCYTF/ City of Morgan Hill, City of Gilroy, representatives, volunteers and employees harmless and release LATI, its volunteers, representatives and employees from any and all liability for any injury or loss which may be suffered by the above named individual in this program. I have read the above application and am in agreement and fully understand that I assume all risks for any injuries received. I have followed all procedures for stated under Registration Procedures. I certify that all the above information is true and accurate.

LATI does not discriminate on the basis of race, color, national origin, religion, sexual orientation, gender identity, disability, age, or familial status in the administration of its programs or activities.

Parent/Legal Guardian Signature (Full Printed Name) By electronically signing this form I agree to the above statement.

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* 9. Date of Signature

Date

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* 10. My relationship to participant(s)

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