Night Games

Permission Form
Participants Name__________________________ Birth
date_______________
Any allergies, including food? Yes No
If yes, what are they?
__________________________________________________
________________________________________________________________
_______
Are you taing any medication? Yes No
If yes, when does it need to !e taen?
__________________________________
"Please note that all medication, including o#er the counter, must !e gi#en to
li!rary staff mem!er upon arri#al$
I, __________________________, understand that I will !e e%pected to
participate, follow rules and respect li!rary staff mem!er decisions& I further
understand that failure to do so will result in a phone call to my parents to !e
piced up no matter what time it is& I also reali'e that since it is a (loc in) if I
choose to lea#e for any reason, I will not !e admitted !ac inside the li!rary and I
will only !e allowed to lea#e with the presence of a parent or guardian&
Please ha#e your parents fill in the information !elow*
I, ______________________________, gi#e my permission for my teen,
______________________________, to participate in the +,+- Night .ames
After/0ours program, 1une 23, 2345, from 6pm to 7*83pm at the +i!rary, 2233
Pioneer A#enue, ,heyenne, 9Y& I understand that I am responsi!le for my
teens transportation to and from the li!rary as well as any une%pected early pic
up& :eens must !e piced up !y 7*33 pm& I also understand that there will !e
physical acti#ity, food and other challenges;contests in#ol#ed in the e#ent&
I gi#e the +aramie ,ounty +i!rary -ystem permission to see emergency medical
care for my child should the need arise&
Name of Insurance ,ompany
_________________________________________
Name of Insured*
_____________________________________________________
Policy num!er
________________________________________________________
Please list a num!er where you can !e contacted*
___________________________
OVER
Lucie/contract/YA 2K Loc1 05/16/2014
In exchange for the opportunity to participate in the Laramie County
Library Systems Night Games After!ours" a## participants sha## un$erta%e
any an$ a## ris%s& 'he participant an$(or his or her parent or guar$ian sha##
be #iab#e for any an$ a## ris%s& 'he Laramie County Library System" its
e#ecte$ an$ appointe$ officia#s" emp#oyees an$ agents sha## not be #iab#e
for any in)uries or $amages to any participant in the Laramie County
Library Systems Loc%in" or the property of the participant" or be sub)ect to
any actions" causes of action" $amages" c#aims or $eman$s" inc#u$ing
*ithout #imitation" those $amages resu#ting from acts of neg#igence on the
part of the Laramie County Library System its e#ecte$ an$ appointe$
officia#s" emp#oyees an$ agents& +urther" any participant" for
himse#f(herse#f an$ on beha#f of his or her heirs" persona# representati,es
an$ assigns" $oes hereby" fore,er *ai,e" re#ease an$ $ischarge the
Laramie County Library System" its e#ecte$ an$ appointe$ officia#s" its
emp#oyees an$ agents from a## %no*n or un%no*n persona# in)uries"
property $amage or $eath resu#ting or arising out of his or her participation
in Laramie County Library Systems Loc%in&
-igned ______________________________, Parent or +egal .uardian
If you ha#e any <uestions or concerns please call
Andrew As<uith at ==8/=234 or email aas<uith>+,+-online&org&
Lucie/contract/YA 2K Loc1 05/16/2014