G5 FIRE PARENTAL CONSENT FORM

G5 Fire is an unincorporated association of performance artists that utilize fire to enhance dancing and spinning performances. This organization was created to promote a safe environment for all participants and observers in organized events.

I,__________________________________, hereby certify that I am the parent/legal guardian of __________________________, a minor.

I understand that my child wishes to perform with fire at Gallery 5 at 200 W Marshall St Richmond, VA during the First Fridays Art Walk for the year ________. In consideration of G5 Fire organizing, conducting and allowing my child to participate in G5 Fire activities with my consent, (as testified by my signature below), I hereby undertake and agree that I shall at all times hereafter on behalf of myself, my heirs, and assigns and my legal representative indemnify and keep indemnified any of G5 Fire’s officers, members, servants and agents, successors and assigns or any one or more of them from and against claims, actions, suits, damages, expenses and costs of every nature of description whatsoever which may be made or incurred by reason of or in consequence of:

a) any accident, incident, mishap, injury or loss caused or occasioned either wholly or partially by the participation or non-participation of my above named child in the activity;

b) the manner in which the activity was so organized or conducted;

or

c) the child’s treatment in the course of the activity.

I agree to compensate any damages to any party that might come as result of my child’s actions. I agree to instruct my child to consider any guidelines or recommendations given by the G5 Fire Safety Team.

I understand that performing with fire may be hazardous to my child. I hereby expressly and specifically assume the risk of injury or harm in these activities and release Gallery 5 and G5 Fire from all liability for injury, illness, death or property damage resulting from my child’s activities at Gallery 5.

I hereby further authorize and agree that G5 Fire or its officers, members, servants or agents, successors or assigns may seek and obtain for my child such medical advice and treatments as may be necessary or expedient and I hereby undertake to pay any expenses so incurred.

My child has / does not have (please circle which applies) known medical or physical conditions, including allergies, which may affect his/her participation or be relevant if medical treatment is needed.

If applicable, please list medical conditions below.

Medicare No. (if applicable) ___________________________________________

I agree to be present at all times that my child’s performs with fire at Gallery 5. If I can not be present I shall designate another adult to safely supervise my child’s activities.

I am the Parent/ Guardian of _____________________________________ (Full Name)

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Print Name

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Address

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Cell Phone 1 Cell Phone 2 Home Phone

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Signature Date

Alternative Emergency Contact Information

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Name

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Relation

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Cell Phone 1 Cell Phone 2 Home Phone