Chinquapin Center for the Arts

Chinquapin Center for the Arts

Mail in: Liability Release Form: 

Chinquapin Center for the Arts


 

Full Name:

______________________________________________________________________


Address:

______________________________________________________________________

  

City/State/Zip/Country: ______________________________________________________________________


Telephone: ____________________           Email: _____________________________

  

I, the undersigned, agree to accept all responsibility regarding my, or my guests, participation in any activity at, for, or under the auspices of the Chinquapin Center for the Arts (CCA).  I hereby waive any claim against CCA and the CCA Board of Directors, Staff, and Volunteers for any injury suffered in connection with participation, and I assume all risks and hazards incidental to participation.  I agree to have emergency medical information and emergency contact information on file with CCA.  I hereby waive, release, absolve, indemnify and hold harmless the Chinquapin Center for the Arts, its Board of Directors, Staff, Guests, and Volunteers from any claim arising out of any incident or injury resulting from any activity conducted under the auspices of the CCA.


My signature below indicates that I have been notified of and agree with all of the above conditions.

  

Name: _______________________________________________________________________


Signature:  _____________________________                        Date:_________________