PoP Club Registration
Registration Information
Name of Child *
Your answer
Name of Parent
Your answer
Your answer
Mobile Phone
Your answer
Your answer
Grade in Fall *
Child Age *
Your answer
I, (NAME OF PARENT), as the parent or legal guardian of my child, (NAME OF CHILD), give my permission to participate in the North Iowa Farmers Market/Power of Produce Club.I agree and consent to the following: I give permission for North Iowa Farmers Market/Power of Produce Club to use photos of my child for marketing and promotional purposes without further consent or compensation. I am voluntarily participating in the North Iowa Farmers Market/Power of Produce Club. I agree to assume full responsibility for any risks, injuries or damage, known or unknown, which might incur as a result of participating in the program. I knowingly, voluntarily and expressly waive any claim I may have against the City of Mason City, the North Iowa Farmers Market, or any person or business acting on behalf of the program for injury or damages that my child may sustain as a result of participating in the program.I, my heirs or representatives forever release, waive, discharge and covenant not to sue the City of Mason City or the North Iowa Farmers Market for any injury or death caused by their negligence or other acts. I have read the above waiver and release of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. *
Parent Signature
Parent Name *
Note: by writing your name here, you are signing your name to agree that the above information is true.
Your answer
Date *
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