BrickSpace Emergency Form & Waiver of Liability
This form is required for participation in any BrickSpace program.
* Required
Child's first name
*
Your answer
Child's last name
*
Your answer
Child's date of birth
*
MM
/
DD
/
YYYY
Any allergies or other special considerations?
Your answer
Additional child (sibling) first name
Your answer
Additional child (sibling) last name
Your answer
Additional child (sibling) date of birth
MM
/
DD
/
YYYY
Additional child (sibling) allergies or other special considerations?
Your answer
Parent/guardian first name
*
Your answer
Parent/guardian last name
*
Your answer
Parent/guardian phone number
*
Your answer
Alternate phone number
Your answer
Parent/guardian email
*
Your answer
Home address
*
Your answer
City, state, zip
*
Your answer
EMERGENCY CONTACT INFORMATION
Emergency contact 1 - full name
*
Your answer
Emergency contact 1 - phone number
*
Your answer
Emergency contact 1 - relationship to child
*
Your answer
Emergency contact 2 - full name
Your answer
Emergency contact 2 - phone number
Your answer
Emergency contact 2 - relationship to child
Your answer
WAIVER OF LIABILITY
I, the undersigned, in consideration of participation in BrickSpace programming, agree to indemnify and hold harmless, and release, waive and discharge BrickSpace and its employees from and against any and all liability for injury or property damage which may be suffered by the above named participant rising out of, in any way connected with participation in the program. I have read the above and hold harmless and release agreement and fully understand that I assume all risks for any injuries and property damage suffered.
PHOTO RELEASE
I, the undersigned, understand and agree that BrickSpace reserves the right to use any photograph/video taken at any event/class, without the expressed written permission of those included within the photograph/video. BrickSpace may use the photograph/video in publications or other media material produced, including but not limited to brochures, invitations, books, newspapers, magazines, websites, social media sites, etc.
E-SIGNATURE
By entering their full name, the individual named below is signing this BrickSpace emergency form and liability waiver electronically and agrees this electronic signature is the legal equivalent of his/her manual signature.
Full Name of Parent or Legal Guardian
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
LEGO®, the LEGO logo, and the brick and knob configuration are trademarks of the LEGO Group. ©2010 The LEGO Group
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