Please support us by linking your Kroger Plus card to Mountain Mentors. When you shop Kroger donates a percent of your purchases to us. This in no way affects the discount you receive or the cost of your purchase. Basically its a win-win. All you have to do is enroll your card through an email address. Click here for instructions.
Student Waiver
Embedded Scribd iPaper - Requires Javascript and Flash Player
Mountain Mentors Student Waiver
Name __________________________________________________________________________________ School Grade Age Address_________________________________________________________________________________
Street Address Work Home City, State Cell Zip
Phone __________________________________________________________________________________ Residential or custodial Parent(s)/ Guardian(s) 1. Mother¶s Name _________________________________________________________ Address ___________________________________________________________________________
Street Work Home City, State Zip Cell
Phone _____________________________________________________________________________ 2. Father¶s Name _____________________________________________________________________ Address ___________________________________________________________________________
Street Work Home City, Cell State Zip
Phone_____________________________________________________________________________
I____________________________for myself, my child______________________________, and my/our
heirs, executors, administrators and assigns, do hereby waive, release and forever discharge and agree to indemnify and defend Mountain Mentors, its members, officers, administrators, employees, volunteers, servants, and agents from and against all claims, demands, or causes of action by any person or entity, for any theft, loss, cost, injury, death, or damages whatsoever arising from or claimed to arise from or in any way connected with the named child¶s participation in the Mountain Mentors program and activities.
_____________________________ Date
___________________________________________ Signature of Parent or Guardian
Mountain Mentors Student Waiver
Name __________________________________________________________________________________ School Grade Age Address_________________________________________________________________________________
Street Address Work Home City, State Cell Zip
Phone __________________________________________________________________________________ Residential or custodial Parent(s)/ Guardian(s) 1. Mother¶s Name _________________________________________________________ Address ___________________________________________________________________________
Street Work Home City, State Zip Cell
Phone _____________________________________________________________________________ 2. Father¶s Name _____________________________________________________________________ Address ___________________________________________________________________________
Street Work Home City, Cell State Zip
Phone_____________________________________________________________________________
I____________________________for myself, my child______________________________, and my/our
heirs, executors, administrators and assigns, do hereby waive, release and forever discharge and agree to indemnify and defend Mountain Mentors, its members, officers, administrators, employees, volunteers, servants, and agents from and against all claims, demands, or causes of action by any person or entity, for any theft, loss, cost, injury, death, or damages whatsoever arising from or claimed to arise from or in any way connected with the named child¶s participation in the Mountain Mentors program and activities.
_____________________________ Date
___________________________________________ Signature of Parent or Guardian
This document has been released into the public domain.
| Attachment | Size |
|---|---|
| MM Waiver.child_.docx | 13.28 KB |
