2019 Summer Feeding Program
Name *
Your answer
Age (all participants must be 18 and younger) *
Your answer
Please list any food allergies or type N/A if not applicable. *
Your answer
Phone number *
Your answer
Address *
Your answer
Attention: Transportation services are available! Pick-up and Drop-off services are available to Picture Lake, Green Acres and Harrison's Mobile Park.
Are you interested in this transportation service? *
General Release of Liability and Indemnification
***IMPORTANT NOTICE: PLEASE NOTE THIS SECTION MUST BE COMPLETED BY A PARENT/GUARDIAN IF THE CHILD IS UNDER THE AGE OF 18.
In consideration of participation in this activity, I do hereby assume all risk of injury to the named participant and I will along with my heirs, successors and assigns, indemnify, hold harmless and release the County of Dinwiddie, the Dinwiddie County Board of Supervisors, the Dinwiddie County Parks and Recreation Department, Dinwiddie Department of Social Services, and all their officers, agents, employees, staff, volunteers, successors from any and all liability, actions, causes of actions, claims of demands of every kind of nature whatsoever, which arises of, or in connection with participation in the activity. I also agree to allow transportation of the participant to the nearest physician or hospital for medical treatment and agree to allow for immediate first aid to injured participant when deemed necessary.
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