Release And Waiver Of Liability And Program Participation Agreement University Of Arkansas Education Abroad Programs Page 2

ALL RIDERS MUST BRING THEIR OWN HELMET AND WEAR IT!!!*

REVOLUTION457 SKATEBOARDING INFO SHEET

PARTICIPANT SIGNATURE (if 18 or older) :________________________________

Date Signed________________________

Date of Birth:___________________________

Name:_______________________________________

Address:___________________________________________

Apt. #:________________________________E-Mail:____________________________

City:___________________________________Province:

Zip:

Home Phone:____________________________ Emergency Phone:___________________

DOCTOR to be notified in case of emergency:____________________________

PARENT/LEGAL GUARDIAN SIGNATURE______________________________________

Date signed_______________________

BELOW = STAFF USE

REVOLUTION457 // LWCA WITNESS SIGNATURE:_____________________________

Date Signed:_________________________

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