Registration Form
Registration Form for Emma's House Inc.'s Groups
Participant's Full Name: *
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Date of Birth: *
MM
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DD
/
YYYY
Phone Number: *
Your answer
Email: *
Your answer
Gender *
Required
Emergency Contact Name and Number:
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Program: *
Comments
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Agreement: By signing this form, you agree that you have the legal right to register the above said participant. You are granting permission to Emma’s House Inc., to use images (photographs/videos) of the participant for media publications such as email, website, videos, brochures but not limited to above said resources. I hereby waive any right to inspect or approve the finished photographs/videos or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. I, on behalf of the minor participant, hereby assume all risk of accidental personal injuries, sickness, death, damage and expense as a result of participation in activities. I hereby release and forever discharge and agree to hold harmless Emma’s House Inc,, its directors, employees, volunteers, facilitators, etc. from any and all liability, claims or demands for accidental injury, sickness, death, property damages and expenses of any nature incurred by the undersigned and participant while involved in program activities.
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Signature: *
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