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2019 Valley Fuse Waiver/Release Form
Student Release and Hold Harmless Agreement/Image Waiver
Name of Participant *
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Participant's Cell #
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Participant's Address *
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Name of Parent/Legal Guardians *
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Parent/Legal Guardian City *
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Parent/Legal Guardian Zip Code *
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Parent/Legal Guardian Cell # *
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Parent/Legal Guardian Email *
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Emergency Contact Name *
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Emergency Contact's Relationship to Participant *
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Emergency Contact’s Phone # *
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List of Allergies or Medical Conditions
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