Teen Laser Tag

Permission Form
Participants Name___________________________ Birthday_______________ Any allergies, including food? Yes No If yes, what are they? __________________________________________________ _______________________________________________________________________ Are you taking any medication? Yes No If yes, when does it need to be taken? __________________________________ (Please note that all medication, including over the counter, must be given to library staff member upon arrival) I, __________________________, understand that I will be expected to participate, follow rules and respect library staff member decisions. I further understand that failure to do so will result in a phone call to my parents to be picked up no matter what time it is. I also realize that since it is a lock in if I choose to leave for any reason, I will not be admitted back inside the library and I will only be allowed to leave with the presence of a parent or guardian. Please have your parents fill in the information below: I, ______________________________, give my permission for my teen, ______________________________, to participate in the LCLS Teen Laser Tag After-Hours program, November 15, 2013, from 6pm to 8:30pm at the Library, 2200 Pioneer Avenue, Cheyenne, WY. I understand that I am responsible for my teens transportation to and from the library as well as any unexpected early pick up. Teens must be picked up by 8:30 pm. I also understand that there will be physical activity, food and other challenges/contests involved in the laser tag event. I give the Laramie County Library System permission to seek emergency medical care for my child should the need arise. Name of Insurance Company _________________________________________ Name of Insured: _____________________________________________________ Policy number ________________________________________________________ Please list a number where you can be contacted: ___________________________ OVER

Lucie/contract/YA 2K Loc1

11/04/2013

In exchange for the opportunity to participate in the Laramie County Library Systems After-Hours, all participants shall undertake any and all risks. The participant and/or his or her parent or guardian shall be liable for any and all risks. The Laramie County Library System, its elected and appointed officials, employees and agents shall not be liable for any injuries or damages to any participant in the Laramie County Library Systems Lock-in, or the property of the participant, or be subject to any actions, causes of action, damages, claims or demands, including without limitation, those damages resulting from acts of negligence on the part of the Laramie County Library System its elected and appointed officials, employees and agents. Further, any participant, for himself/herself and on behalf of his or her heirs, personal representatives and assigns, does hereby, forever waive, release and discharge the Laramie County Library System, its elected and appointed officials, its employees and agents from all known or unknown personal injuries, property damage or death resulting or arising out of his or her participation in Laramie County Library Systems Lock-in. Signed ______________________________, Parent or Legal Guardian If you have any questions or concerns please call Andrew Asquith at 773-7201 or email aasquith@LCLSonline.org.

Lucie/contract/YA 2K Loc1

11/04/2013