Your Name *

First Name

Last Name

Your Child's Name 1 *

First Name

Last Name

Your Child's Date of Birth 1 *

MM

DD

YYYY

Your child's name 2

First Name

Last Name

Your child's Date of Birth 2

MM

DD

YYYY

Your child's name 3

First Name

Last Name

Your child's Date of Birth 3

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact #1 *

First Name

Last Name

Emergency Contact #1 *

(###)

###

####

Emergency Contact #2 *

First Name

Last Name

Emergency Contact #2 *

(###)

###

####

Your child(ren)'s doctor's Name *

First Name

Last Name

Your child(ren)'s doctor's Phone *

(###)

###

####

I give my permission to Mori-no-ie to use photos/videos of my child(ren) and myself *

Yes

No

Terms and Agreement *

I, (Print parent/guardian's name)_____________________, and the parent/guardian of (Print child's name below) ____________________, confirm that the above information is correct and complete. I, give permission for my child (Print child's name below), _______________to attend all the class activities of Mori-no-ie, except as specifically noted above. This includes permission to go to neighborhood parks during class. I acknowledge that the nature of the class activities may expose myself and my child hazards or risks that may result in personal injury. I expressly assume all risks for myself and my child to participate in these class activities. In the event that I cannot be reached in an apparent medical emergency, I authorize Mori-no-ie, its personnel, agents or volunteers, to obtain and/or administer emergency medical aid to said minor. I, hereby, waive and release any and all claims, actions, lawsuits and/or legal proceedings of said minor or I might have against Mori-no-ie arising out of any injury, illness, death, or property damage that the minor or I might sustain or endure, whether as a result of negligence of Mori-no-ie workers, employees, agents, directors, or otherwise. And I understand and agree that I am solely responsible for any medical expenses and/or other costs arising out of such injuries or illness.

I Agree

I Disagree

Parent/Guardian's name

First Name

Last Name

Child(ren)'s name

First Name

Last Name