Benicia USD Cooking Club Program Registration Form
Student Information
Name *
Your answer
Grade
Your answer
School *
Your answer
Address
Your answer
Allergies *
Your answer
Medications
*Used to prevent/reduce Medicine-Food interaction complications.
Your answer
Cooking Experience
(Check which applies)
Parent Information
Name
Your answer
Phone
Your answer
Email
Your answer
Emergency Contact
Your answer
Emergency Contact Phone
Your answer
Relationship
Your answer
Comments
Your answer
Waiver of Liability
I, the undersigned, in consideration of participation in the program(s) listed above, agree to indemnify and hold harmless, and release, waive and discharge the Benicia Unified School District (BUSD) and Healthy Cooking with Kids, Inc. (HCK, Inc.), its elected or appointed officers, officials, employees, agents and volunteers from and against any and all liability for injury or property damaged which may be suffered by the above named participant(s) rising out of, in any way connected with participation in the program(s), including injuries due to the active or passive negligence of the BUSD or HCK, Inc., its officials, employees, agents and volunteers.

I HAVE READ THE ABOVE HOLD HARMLESS AND RELEASE AGFREEMENT AND FULLY UNDERSTAND THAT I ASSUME ALL RISKS FOR ANY INJURIES AND PROPERTY DAMAGE SUFFERED.

Signature of Parent/Guardian *
Your answer
Date *
MM
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