Parent/Guardian Name

First Name

Last Name

Phone

Child #1 Name

First Name

Last Name

Child's age

Child #2 Name

First Name

Last Name

Child's age

Child #3 Name

First Name

Last Name

Child's age

Does your child have asthma, allergies or any other medical condition we need to be aware of? If yes, please give details

Additional Emergency Contact

First Name

Last Name

Emergency Contact Phone

Emergency Contact Relationship

Medical Emergency

By ticking this box the parent/guardian gives permission to Big Wild Imagination to seek medical treatment for the participant in the event that a parent/guardian cannot be reached.

Release of Liability

By ticking this box the parent/guardian releases Big Wild Imagination from all liability and claims related to any loss, damage or injury that may be sustained by the participant while on the premises and under the supervision of Big Wild Imagination.

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