I2I Permission Agreement Choose The Camp Location & Date: 06/21/2008 - Fitzgerald Park || Tucker, GA 07/18/2008 - Weynoah High School || Birmingham, AL Youth Full Name: Age: 6 7 8 9 10 11 12 13 14 15 16 17 Grade: 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Address: City: Zip: State: AL AKASAZARCA COCTDEDCFM FLGAGUHIID ILINIAKSKY LAMEMHMDMA MIMNMSMOMT NENVNHNJNM NYNCNDMPOH OKORPWPAPR RISCSDTNTX UTVTWAWVWI WY   Phone: Phone format (###) ###-#### Email: Cell: Parent/Legal Guardian Full Name: Cell: Email:   Emergency Contact  Name: Phone: T-Shirt Size Youth: Small Medium Large XL XXL   Adult: Small Medium Large XL XXL Liability/Medical Treatment Waiver Release PLEASE NOTE: We strongly recommend each participant have some type of accident medical insurance for her own protection. Physician's  Name: Phone: Date of Last Tetanus Immunization: Medicine Allergies: none Existing Medical Conditions: none Optional Photo / Video Release I hereby grant to Irons 2 Impact, Inc. (“I2I”) permission to photograph, record, and video myself and/or my child, and to use all or any part of the results of such photography, recording, and video for instructional and promotional purposes. I understand that Irons 2 Impact, Inc. (“I2I”) may use such material for media, radio, television, video cassette, compact disk, digital video disk, internet content, etc. It is understood that this authorization is made freely without compensation. Initials of Participant:  Parent/Guardian: I (the parent or legal guardian), by clicking submit understand that you that in consideration of the request and permission to participate in the referenced activity herby assume full responsibility for all risk of injury or loss which may result from my child’s participation in the activity and herby agree to hold harmless and release and forever discharge Irons 2 Impact, Inc. (“I2I”), their instructors, employees or volunteers, from any and all claims and demands whatsoever which the undersigned, and any of them or any third person and the representative thereof, or any persons acting under their behalf have or may have against Irons 2 Impact, Inc. (“I2I”) or their instructors, employees or volunteers by reason of any accident, illness, injury to or death of and person or persons, or damage to or loss or destruction of any property arising or resulting directly or indirectly from participation in the aforementioned activity and occurring during said participation or any time subsequent thereto, save and expect that the above provisions shall not be applicable to injury or death of persons or damage to or loss of property arising out of the neglect or intentional acts of the Irons 2 Impact, Inc. (“I2I”.) The terms of this release will serve as a release and assumption of risk for my heirs, executors, and administrators for all my family members. During this activity, your child understand that any misconduct on their part will result in immediate removal and/or dismissal from camp and non-participation in future activities and that severe misconduct will result in the immediate notification of parent/guardian. I understand that my son/daughter will be responsible for all transportation to and from each designated camp location. I Want To Pay Now I Will Pay Later    Please verify all information and desired location is selected before submitting.