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Tubby & Coo's Mid-City Book Shop Summer Reading Program Registration & Release Form

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Participant Information

First Name *

Last Name *

Date of Birth *

School for Fall 2017 *

Grade Entering *

Parent/Guardian Information

First Name *

Last Name *

Phone *

Medical Consideration

As part of the Summer Reading Program, Tubby & Coo’s Mid-City Book Shop will be providing a light snack. Please list any allergies or food restrictions that need to be taken into consideration.

Allergies/Food Restrictions

Emergency Contact Person(s)

First Name *

Last Name *

Phone *

First Name

Last Name

Phone

Authorized people to pick up participant (in case parent/guardian is unavailable)

First Name

Last Name

Phone

First Name

Last Name

Phone

First Name

Last Name

Phone

Waiver of Release

This is a legally binding Consent Form and Release of Liability made voluntarily by me, the undersigned Releasor, on my own behalf, and on the behalf of my heirs, executors, administrators, legal representatives and assigns to Tubby & Coo’s Mid-City Book Shop and its employees.

The undersigned hereby acknowledges that participation in the above named activity involves low risk of physical injury but assumes all such risks. The undersigned does hereby release and forever discharge Tubby & Coo’s Mid-City Book Shop and its employees of any and all claims, demands, rights and causes of action of whatever kind of nature, arising from and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequence thereof, resulting from participation in or in any way connected with the above named activity. Basically, we are reading, but sometimes accidents happen.

I have read and fully understand the Release and Waiver of Liability Agreement and hereby release Tubby & Coo's Mid-City Book Shop of all claims. *

I give permission to use this participant’s likeness in photographic promotional materials. *

By submitting this form, I hereby acknowledge that I have read and fully understand the Release and Waiver of Liability Agreement listed above and that I release Tubby & Coo's Mid-City Book Shop of all claims and liability.

What is two plus two? *