Registration and Liability Release Form
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Child's Name *
Child's T-Shirt Size
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Parent/Guardian Name *
Parent/Guardian Phone *
I acknowledge that Ness City Public Library may take photographs of me/my child while participating in Summer Reading Program activities and I grant permission for the library to use said photographs for the purpose of promoting and informing the community of library programs. *
Please list all known allergies: *
Please list any physical restrictions: *
This release is for any and all liability for personal injuries and property losses or damage occasioned by, or in connection with, Ness City Public Library Summer Reading Program. The undersigned agrees to abide by all rules and regulations set forth by Ness City Public Library and/or its affiliates throughout the Summer Reading Program. In the event that the individual(s) registered in any Ness City Public Library sponsored program(s) is in need of treatment at any emergency room or medical care facility, the participant’s instructor, or any employee of Ness City Public Library and/or other sponsoring agencies, has my consent to authorize treatment for the participant(s) by the doctor(s) of their choosing as the doctor(s) may deem necessary if I cannot be reached. I, the undersigned, do hereby acknowledge that I have granted permission for me/my child to participate in any and all Ness City Public Library program(s) with full knowledge of the risks involved and I hereby agree to assume those risks and to hold Ness City Public Library, other sponsoring agencies and all of their representatives free from liability for any injury, harm, or complication resulting from said participation in any and all program(s). Furthermore, I do understand that accident insurance is not provided by the Ness City Public Library and/or other sponsoring agencies, and I hereby agree to assume full responsibility for any and all medical expenses resulting from any accidents or injuries suffered by me and/or my child while participating in said program(s). *
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On June 30 we will be traveling to Great Bend to visit the Kansas Wetlands Center and Great Bend Zoo. Transportation will be provided. We will leave from Ness City High School at 8 am. Participants will need to bring a sack lunch. Children must be old enough to attend Kindergarten in the fall. Space will be limited to 40 children. Will your child be participating in this field trip? *
On June 23 we will be watching a book-to-movie adaptation. Although it is not a requirement, we highly encourage children to read the story beforehand. We will be hosting an afternoon read-aloud in the weeks leading up to Movie Day. Depending on interest, it could be in-person or virtual. Would your child like to participate? *
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