ImagineWorks Youth Membership Form
Youth Application for IW Membership (To Be Completed by Parent/Guardian)
Student Information
First Name *
Your answer
M.I.
Your answer
Last Name *
Your answer
Gender
Date of Birth *
MM
/
DD
/
YYYY
Allergies *
Parent/Guardian Information
First Name *
Your answer
M.I.
Your answer
Last Name *
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Home Phone
Include area code.
Your answer
Cell Phone *
Include area code.
Your answer
Email Address *
Your answer
Occupation
Your answer
Employer
Your answer
Emergency Contact #1 Name *
Your answer
Emergency Contact #1 Phone Number *
Your answer
Emergency Contact #2 Name
Your answer
Emergency Contact #2 Phone Number
Your answer
Consent
The youth identified above and parent/guardian understands In consideration of gaining membership, authorizing participation in activities and programs of ImagineWorks (IW) and to use its facilities, equipment, machinery, tools, and in addition to the payment of any fee or charge, I do hereby waive, release, and discharge IW and its officers, agents, employees, representative, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in any actives sponsored by IW. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any those mentioned or others acting on their behalf or in any way arisen out of or connected with my participation in any actives hosted by IW or the use of any equipment provided by IW. By signing below I agree to this consent and release agreement. All memberships are non-refundable or transferable.
Electronic Signature *
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of ImagineWorks. Report Abuse