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					                                           Registration Form
Child’s name: _________________________________________ Date of Birth __________

Child’s Parent/Guardian__________________________________ Date of Birth___________

Parent’s Drivers license or Social Security Number___________________________________

Address_____________________________________________________________________

City_____________________ Zip_________ (email)________________________________

Phone # (home) _______________________ (work/cell) ______________________________

Best time to call (home)__________________(work)_________________________________
Person to contact in case of emergency ____________________________________________

                                     Phone # ___________________________________________

Physician Name and Number____________________________________________________

Health Insurance Carrier__________________ Policy #_______________________________

Does your son/daughter take any medications? y/n (if yes please list)
____________________________________________________________________________

Does your son/daughter have any medical conditions that would affect him participating in
classroom or gym activities? y/n (if yes please explain)
_____________________________________________________________________________
_____________________________________________________________________________

Are there activities that your son/daughter should not participate in? y/n (if yes please explain)
_____________________________________________________________________________

Instruction: please give to Mars-Bros Coordinator

                     1260 Kalamazoo SE Grand Rapids MI 49507 (616) 248-2848 fax (616) 452-1763



                                                www.marsbros.org
                                  A Program of Oakdale Neighbors
                                   Parent/Guardian Consent form

I, _____________________________________, am the parent or legal guardian of
_____________________________ (hereinafter "my child"), and I am informed of the activities offered by
Oakdale Neighbors/Mars-Bros Mentoring program located at: 1260 Kalamazoo SE, in the City of Grand
Rapids, County of Kent, and State of Michigan, beginning on the day_________________________. As the
parent or legal guardian of my child, I hereby consent for my child to attend and participate in all activities
provided by Oakdale Neighbors/Mars-Bros mentoring program.

   IT IS MY INTENTION BY THIS AGREEMENT TO EXEMPT AND RELIEVE OAKDALE NEIGHBORS AND ITS
   OFFICERS, AGENTS, SERVANTS OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY
    DAMAGE OR WRONGFUL DEATH OF MY CHILD CAUSED BY ANY ACT OF NEGLIGENCE OF OAKDALE
                  NEIGHBORS AND ITS OFFICERS, AGENTS, SERVANTS OR EMPLOYEES.

For and in consideration of permitting my child to observe, or use any facility or equipment of Oakdale
Neighbors, or engage in and/or receive instruction in any activity or activity incidental thereto SOME OF
WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at Oakdale Neighbors, I hereby
voluntarily and absolutely release, discharge, waive and relinquish any and all loss or damages or actions or
causes of action for personal injury, property damage or wrongful death occurring to my child as a result of my
child's observing or using facilities or equipment of Oakdale Neighbors, or engaging in or receiving instructions
in any activities SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in
activities incidental thereto wherever or however the same may occur, and for whatever period said activities or
instructions may continue.

I, my heirs, executors, administrators or assigns, agree that in the event any claim for personal injury, property
damage, or wrongful death shall be prosecuted against Oakdale Neighbors or its officers, agents, servants or
employees, I will indemnify and hold harmless Oakdale Neighbors and its officers, agents, servants or
employees from any and all claims or causes of action by my child or by any other person or entity, by
whomever or wherever made or presented, and under no circumstances will I present any claim against Oakdale
Neighbors and said persons for personal injuries, property damage, wrongful death or otherwise, caused by any
act of negligence by Oakdale Neighbors and said persons.

I have read this Release, have requested and have been provided with, or have requested and declined
advisement on the potential dangers/risks of engaging in the observation, activities or instruction offered,
assume all risks associated with such dangers and risks, and am fully aware of and understand the terms and the
legal consequences of the signing of this Release. I intend my signature to be a complete and unconditional
release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is
agreed that the balance shall, notwithstanding, continue in full legal force and effect.


________________________________________                                       DATED: _________________

SIGNATURE OF PARENT OR GUARDIAN FOR _________________
                                    (Name of my child)

				
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