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Soapbox Derby
(June 18th, 2011)
ATTENTION: BY SIGNING THIS FORM YOU ARE ACCEPTING THE RISKS INVOLVED
IN PARTICIPATING IN KA-VROOM!
PLEASE READ CAREFULLY! ALL PARTICIPANTS MUST BE AGES 5-14
NAME OF PARTICIPANT: ______________________________________________________________________________
NAME OF PARENT OR GUARDIAN: ____________________________________________________________________
ADDRESS OF PARTICIPANT:___________________________________________________________________________
TELEPHONE NO (1): _____________________________________ BIRTH DATE: DD!
_____________________
MM! YYYY
TELEPHONE NO (2): _____________________________________
EMAIL OF PARENT OR GUARDIAN (1):_________________________________________________________________
EMAIL OF PARENT OR GUARDIAN (2):_________________________________________________________________
DISCLAIMER CLAUSE
Ka-Vroom, its volunteers, and representatives (furthermore to be known as the Ka-Vroom Team
and representing Maple Ridge Secondary School) are not responsible for any injury, loss or damage
of any kind sustained by any person while participating in Ka-Vroom. You are entering in this event
at YOUR OWN RISK.
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Protection of Privacy - The personal information requested on this form will be protected. It will
be used for the purpose of implementing this waiver. Direct any questions about this collection to: Karen Aitken
(Ka-Vroom Coordinator) or the MRSS Ka-Vroom Team at
Email: kavroommrss@gmail.com
Phone: (604) 463-4175 ext. 1119
__________________________________________ ________________________________________
Signature of Participant Signature of Parent/Guardian
__________________________________________ ________________________________________
Printed Name of Participant Printed Name of Parent/Guardian
_______________________________________________________________________________
Note: Document must be copied to a single page back to back when used.
Signed documents must be brought to MRSS (Maple Ridge Secondary School) upon signing.
For more information, visit the official Ka-Vroom Website: mrsska-vroom.blogspot.com
Updated: November, 2010
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