Ponderosa Consent & Release Form
Ponderosa Retreat & Conference Center wants you or your child’s experience to be a safe and healthy one. However, in the event of an accident or illness, it is important that we have the following information.
* Required
Email address
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Your email
NAME of Participant:
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Your answer
DOB of participant:
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MM
/
DD
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YYYY
GENDER of participant:
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Your answer
HOME CONTACT NAME & NUMBER of Parent or Legal Guardian:
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Your answer
CONTACT ADDRESS:
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Your answer
EMERGENCY BACKUP CONTACT (Name & Phone#) This should be different from "CONTACT PERSON" and will be used only if CONTACT is unreachable.
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Your answer
Photo Release Authorization: By checking the box below, you authorize Ponderosa Retreat & Conference Center and assigns the worldwide rights to use, publish or reprint in whole or in part, any statement, picture, video/film, endorsement, quotation or other material while at Ponderosa. The Undersigned acknowledges that the permission granted herein is non-revocable, and that no further payment or acknowledgement is due therein.
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I have read, understand and accept this section.
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