This form must be signed by the camper and his/her legal guardian prior to participation in the

WSBT22 First Alert Weather Camp.

Your child must be dropped off at the WSBT22 First Alert Weather Camp between 9:45AM-10AM
on the day that you are registered. Your child must be picked up at 12:30 on the day they are
registered. Parents may not attend the camp sessions, but are welcome to join us at 12:15 to
watch their child on WSBT22 News at Midday. WSBT is located at 1301 East Douglas Road in
Mishawaka just east of the St. Joseph Regional Hospital. Call 574-247-7979 or email
sleiter@wsbt.com with questions.
I, the undersigned, as the parent and/or legal guardian of the child named below, do hereby give my full
consent and approval for my child to participate in the WSBT22 First Alert Weather Camp at the WSBT
Stations, located at 1301 E. Douglas Rd., Mishawaka, IN.
During the course of WSBT22 First Alert Weather Camp, I understand that pictures or videos of my child
may be taken and he/she may be interviewed by WSBT. These pictures, videos and interviews may be
used by WSBT during a newscast or in future promotional efforts.
In addition to giving my full consent for my child's participation, I do hereby waive, release, discharge and
agree not to sue the owner or operators of any WSBT property or any person or entity connected with
WSBT22 First Alert Weather Camp.
I hereby certify that my child is fully capable of participating in the Weather Camp activities and that my
child is healthy and has no physical or mental disabilities or infirmities that would restrict full participation
in these activities, except as made known to WSBT.
I further agree on behalf of the child listed below, that I shall hold harmless and fully indemnify WSBT and
hereby release WSBT from any and all claims, damages and costs including attorney fees, and causes of
action which may arise from any cause of action made by me or by, through or on behalf of my child.
I acknowledge that I have read and that I understand each and every one of the above provisions in this
waiver, release of liability and indemnification agreement and agree to abide by them.
List any restrictions for the below-named child.
Child's
name___________________________________________________________________________
Signature of Parent or Legal
Guardian_______________________________________________________Date_________________
Emergency Telephone
Number_____________________________________________________________
Restrictions____________________________________________________________________________