Van Buren Conservation District Education Program Liability Waiver
Release and Acknowledgement of Risk and Approval of Photo Publication. If participant is under the age of 18, this document must be signed by his/her legal guardian. Please note that a PARENT OR GUARDIAN MUST ACCOMPANY EACH PARTICIPANT to Wolf Lake State Fish Hatchery for the entirety of the program and are responsible for transportation.
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 Participant's First Name: *
Participant's Last Name: *
Participant's Age: *
Participant's Allergies: *
Special Notes: *
Parent/Guardian First Name: *
Parent/Guardian Last Name: *
Parent/ Guardian Address: *
Parent/Guardian Phone Number: *
Parent/Guardian Email: *
Emergency Contact's First Name: *
Emergency Contact's Last Name: *
Emergency Contact's Phone Number: *
Emergency Contact's Relationship to Participant: *
Assumption of Risk: I certify that I am the parent or guardian of the participant and that I agree to hold harmless and release from liability the Van Buren Conservation District, Wolf Lake State Fish Hatchery, or any employee for any action, claim, or damage that may arise as a result of my child's participation. In the event my child needs emergency or medical treatment, every attempt will be made to contact us, the parent/guardian. In the event I cannot be contacted, I give my permission to the Van Buren Conservation District and Wolf Lake State Fish Hatchery to secure prompt treatment. My signature below affirms that I have read and understood the above document and that I voluntarily, freely, without duress agree to its terms (Sign name and date): *
Photo Publications: I hereby grant the Van Buren Conservation District and Wolf Lake State Fish Hatchery permission to use any photo of the participant and the parent/guardian in attendance at and during any program, project and/or event, in any and all  of its publications, including website entries, brochures, press releases, Facebook posts, and other social media without payment or any other consideration. My signature below affirms that I have read and understood the above document and that I voluntarily, freely, without duress agree to its terms (Sign name and date):      
Which day(s) do you plan to attend? *
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