Little Buttercups Waiver Form

Participant's Name *

Age *

Date of Birth *

If attending a birthday party, name of birthday boy/girl: *

Email Address *

Participant's Legal Guardian *

Street Address *

City *

State *

Zip *

Phone (home)

Phone (cell) *

Are there any physical conditions or limitations that the Little Buttercups staff should be aware of that may affect or limit your child’s participation? *

*If yes, please explain

*Anything else you would like us to know about your child. ( ie. allergies...)

I do hereby give permission for my child to participate in Little Buttercups Educational Play Program located at 615 High Street, Westwood. I understand that he/she is participating in this educational play program at his/her own risk. I specifically agree to waive and release Little Buttercups its employees, agents and officers from any and all claims for loss of damage of property, liability, or personal injury that may arise from the use of Little Buttercups. I have read, understand, and agree to all of the foregoing. I hereby give permission for images of my child and the use of photographs and/or video singularly or in conjunction with other photographs to be used by Little Buttercups, for advertising, publicity, commercial or other business purposes and waive any rights of compensation or ownership there to. I understand that the term "photograph" as used herein encompasses both still photographs and video footage. I hereby release Little Buttercups, and any of its associated or affiliated companies, their directors, officers, agents and employees from all claims of every kind of account of such use. I certify that I am the parent/legal guardian of the individual named above; I have read this release and approve of its terms. *Please note that any allergy information should be communicated directly to the host family. *

Electronic Signature**

** Understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. *

Confirm

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