Waiver of Liability

Class Date(Required)

In consideration for being allowed to participate in the CPR-AED CERTIFICATION class being held at O’Fallon Fire Protection District on the date chosen above, I do hereby release and discharge all sponsors, coordination groups, volunteers, and individuals associated with the event for all claims, damages, demands, or actions of any kind whatsoever and in any manner arising from or growing out of my participation or that of the minor in said event/class. I represent that I am the Parent/Guardian of the participant and will accompany the minor throughout the entirety of the Class.

Parent or Guardian Name(Required)

First Last

Email(Required)

Home Phone

Cell Phone

Parent/Guardian Address(Required)

Street Address City State ZIP Code

Participant's Name(Required)

First Last

Participant's Age(Required)

Date of Birth(Required)

Participant's Address, if different from Parent/Guardian Address

Street Address City State ZIP Code