Fifth Grade Party at Adventure Park Permission/Waiver

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Description: ATTENTION FIFTH GRADE STUDENTS AND PARENTS... Join us to celebrate the end of your elementary school years. Our package will include 2 Go Kart rides, 4 hours use of the Wild West and Wildcat Roller Coasters, Scramble, Tilt A Whirl, Laser Tags, Rope Course, Rock Wall, Bumper Cars, Mini Golf, and Carousel, etc. NOT INCLUDED: Skycoaster, Hologate Virtual Reality, arcade or midway games, mining station. Dinner will be provided and you MUST select your choices below. THIS IS NOT A DROP OFF EVENT! PARENTS ARE RESPONSIBLE FOR THEIR OWN CHILDREN DURING THIS PARTY. URBANA ELEMENTARY SCHOOL IS NOT INVOLVED IN THE PLANNING OR HOSTING OF THIS EVENT. PLEASE DIRECT ALL QUESTIONS TO: Ilene Smith or Janine Pettay.

Cost/Dates: Cost is $22/student. Friday, June 14, beginning at 5:00 pm and will end promptly at 9:00 pm (closing of Adventure Park).

PLEASE BE SURE TO FILL OUT EACH SECTION OF THE WAIVER. ANY MISSING INFORMATION WILL KEEP YOUR CHILD FROM PARTICIPATING IN THE PARTY. A WAIVER MUST BE COMPLETED FOR EACH STUDENT, EVEN IF THEY ARE IN THE SAME FAMILY. YOU MUST ALSO SUBMIT PAYMENT THROUGH THE PAYPAL LINK TO BE ADDED TO THE ROSTER FOR THE PARTY.

Email *

The following student has permission to participate in the FIFTH GRADE PARTY AT ADVENTURE PARK (Must List Student's First and Last Names) If a sibling is attending, fill out a separate waiver for EACH individual. *

Teacher *

Parent 1 Name *

Parent 1 Phone Number *

Alternate Phone Number for Parent 1 *

Parent 2 Name

Parent 2 Phone Number

Alternate Phone Number for Parent 2:

Are there any medical conditions we should be aware of? *

Yes

If you answered yes to the previous question, please explain.

I understand that it is my responsibility to supervise my child during this party and a responsible adult will be onsite during the party. *

Yes, I will be at the party.

I will not be at the party, but my child will be in the care of another adult who will be in attendance. (MUST GIVE THE NAME OF ADULT BELOW)

Name of person supervising my child if other than myself.

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