Student Name *

First Name

Last Name

Parent/Guardian *

First Name

Last Name

Cell Phone *

(###)

###

####

Parent/Guardian

First Name

Last Name

Cell Phone

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Cell Phone *

(###)

###

####

Liability Waiver *

I am the parent/guardian of the student named below and hereby give permission for him/her to participate in the after-school Super Duper Hooper Club administered at Annunciation Day School by Grace Jacobi and Hilary Riall. At this time, he/she is not under a physician's care. I understand if a health issue arises, I will notify Grace Jacobi as soon as possible. I hereby agree on behalf of myself and the child’s other parent/guardian (if applicable), to release, indemnify, and hold harmless the Annunciation Day School, the Annunciation Greek Orthodox Cathedral of Atlanta, the Greek Orthodox Metropolis of Atlanta, and each of their respective employees, officers, directors, representatives, volunteers, and agents from any claims, actions, liabilities, damages, and expenses, including attorneys’ fees, concerning any accident, injury, or death involving my child or any other individual that occurs during or as a result of my child’s participation in the after school Super Duper Hooper Club, all to the fullest extent permitted by the laws of the State of Georgia.

Signature *

I understand that checking this box and providing my name below constitutes a legal signature to the above mentioned Liability Waiver.