Fifth Grade Party at Adventure Park Permission/Waiver
Description: ATTENTION FIFTH GRADE STUDENTS AND PARENTS... Join us to celebrate the end of your elementary school years. Our package will include 2 Go Kart rides, 4 hours use of the Wild West and Wildcat Roller Coasters, Scramble, Tilt A Whirl, Laser Tags, Rope Course, Rock Wall, Bumper Cars, Mini Golf, and Carousel, etc. NOT INCLUDED: Skycoaster, Hologate Virtual Reality, arcade or midway games, mining station. Dinner will be provided and you MUST select your choices below. THIS IS NOT A DROP OFF EVENT! PARENTS ARE RESPONSIBLE FOR THEIR OWN CHILDREN DURING THIS PARTY. URBANA ELEMENTARY SCHOOL IS NOT INVOLVED IN THE PLANNING OR HOSTING OF THIS EVENT. PLEASE DIRECT ALL QUESTIONS TO: Ilene Smith or Janine Pettay.

Cost/Dates: Cost is $22/student. Friday, June 14, beginning at 5:00 pm and will end promptly at 9:00 pm (closing of Adventure Park).

PLEASE BE SURE TO FILL OUT EACH SECTION OF THE WAIVER. ANY MISSING INFORMATION WILL KEEP YOUR CHILD FROM PARTICIPATING IN THE PARTY. A WAIVER MUST BE COMPLETED FOR EACH STUDENT, EVEN IF THEY ARE IN THE SAME FAMILY. YOU MUST ALSO SUBMIT PAYMENT THROUGH THE PAYPAL LINK TO BE ADDED TO THE ROSTER FOR THE PARTY.

Email address *
The following student has permission to participate in the FIFTH GRADE PARTY AT ADVENTURE PARK (Must List Student's First and Last Names) If a sibling is attending, fill out a separate waiver for EACH individual. *
Your answer
Teacher *
Your answer
Parent 1 Name *
Your answer
Parent 1 Phone Number *
Your answer
Alternate Phone Number for Parent 1 *
Your answer
Parent 2 Name
Your answer
Parent 2 Phone Number
Your answer
Alternate Phone Number for Parent 2:
Your answer
Are there any medical conditions we should be aware of? *
If you answered yes to the previous question, please explain.
Your answer
I understand that it is my responsibility to supervise my child during this party and a responsible adult will be onsite during the party. *
Name of person supervising my child if other than myself.
Your answer
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