Name: Male Female

Address:

City: State: Zip: Phone:

Birth date: Referring Org/Group/Individual (optional):

Full Parent/Guardian Name:

Address:

City: State: Zip: Phone:

E-mail:
Years in Fairway Foundation Program: Current Level: Tiger Jr. Cub

Ethnicity: African American Caucasian Asian Native American
Latino/Hispanic Other
Please specify any medical or special needs of which the Fairway Foundation should be aware:

I give permission for the above registrant to participate in the Fairway Foundation’s 2006 clinics and other programs, I assume all risks and hazards incidental to the conduct of this activity, including any transportation that I do not provide or arrange for. I agree that his/her ability to participate is conditioned on our agreements to assume all risks and hazards associated with such participation, and this agreement to release the Fairway Foundation, its directors, officers, employees and other representatives from any known or unknown claims, causes of actions, damages, or other liabilities of any kind relating to or arising out of such participation. (Please cross out the following paragraph before signing if you do not wish to grant rights to use of your child's name or recorded images). Additionally, I acknowledge that the Fairway Foundation may photograph or record Fairway Foundation clinics or other programs for fundraising, promotional or other purposes, or may authorize others to do so. I hereby consent to such use of my child's name, voice, photographs or other recorded images on an unrestricted basis and without compensation.

Submitted By: Status: Parent Legal Guardian

Phone: Home: Work Cell:
Emergency Contact: Phone:
Relationship to child:

Contact Information

The Fairway Foundation
PO Box 80658
Minneapolis, MN 55408-8658
Phone: 612-870-1213
OR registration@fairwayfoundation.org

www.fairwayfoundation.org