Ozark-Dale County Public Library Pokmon Lock-In Registration and Release Form for Attendees under age 19

Child Name: _________________________________________________________________________ Address, City, ST, and Zip: ______________________________________________________________ Home/Cell Phone: _____________________ Age: _______ Birthdate (Mo/Day/Yr): ____/____/_____

ATTENTION READ CAREFULLY. THIS IS A RELEASE FORM.

I, _______________________________________, hereby give my consent as the parent/guardian of ______________________________, for his/her involvement in the Ozark-Dale County Public Librarys LOCK-IN at the Ozark-Dale County Public Library, Saturday, June 23, 2012 4:00 p.m. until Sunday, June 24, 2012, 9:00 a.m. Ozark-Dale County Public Library workers and adult chaperones will provide supervision. I understand that my son or daughter, once at the Lock-In, will NOT be allowed to leave unless escorted by a parent or legal guardian. It is understood that all possible caution will be taken by those persons in charge to prevent injuries, but neither the chaperones nor the Library will be held responsible in case of an accident. I understand that if my child is not behaving in a manner appropriate to the objective of the Lock-In, I may be contacted prior to the end time of 9am. I agree that if contacted to pick up my child that I will come to the Library and take my child home. Otherwise, I agree that I will either pick my child up at the designated time or have arranged for other means of transportation for them. I agree that my child cannot be picked up or dropped off unless signed in and out at the door. I agree not to hold the Ozark-Dale County Public Library and/or the adult chaperones responsible for any accidents or mishaps which may involve my child. If my child should become seriously ill or injured, I authorize you to arrange for any emergency medical care needed. It is understood that I (the undersigned parent or guardian) will be responsible for expenses incurred in the event of such treatment. I hereby authorize any adult representative of the Ozark-Dale County Public Library to consent to any medical treatment of above named child, which in the judgment of a recognized medical facility, under the general or special supervision of a licensed physician, may be deemed necessary. Phone #(s) to reach parent/guardian in an emergency: ________________________________________ Any Allergies: __________________________ Any Medications: _____________________________ Health Insurance Company: ____________________________ Policy #: _______________________ Family Physician: ___________________________Physician Phone: ___________________________ I hereby declare that I am of adult age; I have carefully read the foregoing release and know the contents thereof, that my child may not use the services or facilities of the Ozark-Dale County Public Library without signing this release and that I sign it as my own free act. Signed: _______________________________________________ Date: ______________
Parent/Guardian