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AffI{mX C: PARESIT'S/ {}SA}LPIAI{*S S$$SEfitr r&ffi}fr

Ilfera+ ef l"earner:
Bste of -sirtht
Fareat'* I &t:asd&ae'* Sass E

Elata*inaelrfn
ITY.E!'Vt.E *n Isarrer.

EEom* &ddresrr
Gon**et Hureber/sl l

'F{*!s *€ e"Eaa 6e*€wi*lr.

trfeaue: Fate of Activtty:

. As ti:e p*sea**/g**rdiaet ef the a.hevemeatr**ed lsarraer, X t:erebg acknowiedge

that I have b;en ir:f,arrned of the deta'ils of the oFcampus activity and voluntarily
and fre*Fy elect to participate irr this *Fc*mpus actkrity. Furthermareo I understaRd
the risk* aes*dated with a* *ff-carcpus activiqy and agree t!:at f&e rr:lee sr3.d
regulations established. for the said activity are for the safety and security of the
participant*, and thu* agree to inst:nrct nry ehitd CIr skildren trl obey ?}:crs.

Havir:g understood all tJre aforernentioned, I hereby consent to allorr my child

or ehiicire$ t* parrieipate, aci+xr*wieiiging ail cf tire icregcirag. i *ta aiso scleiy
re*pon*ibtre f*r pr*viding travel in*ura:rce and any expenses for my chiid or eirildrenns
participation in th* activity.

Ferentl Gtardian's Narne acrd t ,al?

Simailrre

ffogg {otfter infunxafr"on yoa ffyay wisi? te infvrm ,#te i*t*er, sccct? af €hli6'5 mesfi*af
cor?ditt*fi, etc.j: