Homeschool Program : Education : Humane Society of Charles County, Inc.

Humane Education Event Registration

Parent/Guardian Full Name

First Name *

Last Name *

Phone Number (Required)

Phone Number

E-mail Address (Required)

Email Address

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Street Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Child's Name

First Name *

Last Name *

Child's Age (Required)

Child's Age

Emergency Contact (Required)

Name and Relationship (if parent or guardian can not be reached)

Emergency Contact Phone Number (Required)

Emergency Contact Phone Number

Emergency Authorization

Emergency Authorization: By checking I AGREE, I hereby give permission to The Humane Society of Charles County and/or any contact person listed above authorization for treatment for my child in the event I cannot be reached in an emergency.

I AGREE
I DO NOT AGREE

Health History

Explain Health Issues

Please specify any health issues below

Medications

Please List

(Required)

Date of Last Tetanus

Health Insurance (Required)

Health Insurance Provider and Policy Number

Physician Name (Required)

Physician Name

Physician Phone Number (Required)

Physician Phone Number

Type Name Here (Required)

Permission: By typing my name in the box, I hereby certify that I am the parent/guardian of the registered child and I give my permission for him/her to participate in the Humane Society of Charles County, Inc. Humane Education program wherever said program occurs, including transportation from one location to another.

Waiver: By checking I AGREE, Regarding participation in said program, I do hereby release and discharge, for myself and the Participant, and for our heirs, representatives, executors, administrators, successors and assigns and do hereby remise and release and forever discharge the Humane Society of Charles County, Inc. (“Releasee”), its officers, directors, agents, employees, independent contractors, parent and subsidiary corporations, and all other entities in any way related to Releasee, and all other persons however associated with Releasee, in any capacity, their heirs, executors, administrators, insurers, successors and assigns, and any and all other persons, firms, corporations, associations, of and from any and all causes of action, suits, rights, judgments, claims and demands of whatever kind, including, but not limited to any claims in law or in equity, known or unknown, which I and the Participant now have or may hereafter have, now or in the future, including any legal liability of Releasee arising from or by reason of any damage, compensatory or punitive, known or unknown, foreseen or unforeseen, which heretofore have been or which hereinafter may be sustained by me or the Participant ,arising or any way relating to any and all claims and actions.

I AGREE
I DISAGREE

Photo Release: By checking I AGREE, I certify I am the parent or legal guardian of the registered child and hereby give the Humane Society of Charles County, Inc., my permission to take photos of him/her. I acknowledge that these photos are the property of the Humane Society of Charles County, Inc., and may be used by them for any purpose consistent with their mission statement, including but not limited to advertising and marketing.