ADULT PARTICIPANT WAIVER, RELEASE OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNIFICATION WAIVER

EVENT:City of North Miami 5K Turkey Trot
EVENT DATE: 11/26/2026
EVENT LOCATION: City of North Miami, Florida

This Adult Participant Waiver, Release of Liability, Assumption of Risk, and Indemnification Agreement (the “Agreement”) is entered into electronically by the undersigned adult participant (“Participant”) in favor of Fired Up Athletic Force Inc, as the event organizer (“Organizer”); Pure Gold Athletics Corporation, doing business as Pure Gold Timing, as the official timing provider (“Timing Provider”); and the City of North Miami, Florida, including its elected officials, officers, employees, agents, representatives, departments, and volunteers (“City”). The Organizer, Timing Provider, and City, together with their respective affiliates, owners, directors, officers, employees, agents, contractors, representatives, volunteers, sponsors, successors, and assigns, to the extent applicable, are collectively referred to as the “Released Parties.”

1. ACKNOWLEDGMENT AND ASSUMPTION OF RISK

I understand that participation in a road race, running event, walking event, or related athletic activity involves inherent and other foreseeable risks of injury, illness, property damage, disability, or death. These risks include, without limitation, falls; slips and trips; collisions with other participants, pedestrians, vehicles, bicycles, or objects; uneven, wet, slippery, obstructed, or defective surfaces; potholes; curbs; traffic and road crossings; interactions with motorists; heat, humidity, rain, lightning, wind, and other weather conditions; dehydration; heat exhaustion; heatstroke; overexertion; cardiac events; musculoskeletal injuries; exposure to infectious illnesses; inadequate personal hydration or preparation; crowd conditions; equipment failure; timing devices, mats, cables, barriers, cones, and other race infrastructure; actions or omissions of other participants or third parties; and delays in the provision of emergency medical assistance. I understand that these risks may arise from my own actions, the actions of others, environmental conditions, or circumstances beyond the reasonable control of the Released Parties. I voluntarily accept and assume all inherent and other risks associated with my participation, whether known or unknown, foreseeable or unforeseeable, to the fullest extent permitted by Florida law.

2. RELEASE AND WAIVER OF LIABILITY

To the fullest extent permitted by applicable law, I, on behalf of myself and my heirs, executors, administrators, personal representatives, successors, and assigns, hereby release, waive, discharge, and covenant not to sue the Released Parties for any and all claims, demands, causes of action, damages, losses, liabilities, costs, or expenses arising out of or relating to my registration for, preparation for, travel to or from, participation in, or presence at the Event, including claims for personal injury, bodily injury, illness, disability, death, or property damage, to the extent arising from the inherent risks of the Event or otherwise lawfully waivable under applicable law. This release is intended to include claims arising from the ordinary negligence of a Released Party, but only to the extent such claims may lawfully be released under applicable law. Nothing in this Agreement releases any liability that cannot legally be waived, including liability to the extent caused by gross negligence, reckless conduct, or intentional misconduct where such liability is not waivable under Florida law. I understand that this Agreement is intended to be interpreted as broadly as Florida law permits.

3. EVENT ORGANIZATION, SAFETY, AND RESPONSIBILITY

I understand that Fired Up Athletic Force is the Event organizer and is responsible for organizing and coordinating the Event within the scope of its contracted duties, which may include race administration, participant communications, course coordination, event logistics, and coordination with appropriate public agencies and service providers. I understand that Pure Gold Timing is engaged to provide official race timing and related timing services and is not, solely by virtue of that role, the overall Event organizer, traffic-control authority, emergency medical provider, or guarantor of course safety. I further understand that the City of North Miami is the municipal client and may provide or authorize municipal services, facilities, road-use arrangements, or other support as applicable. Each party’s actual responsibilities are governed by its applicable agreements, permits, and legal obligations. No provision of this Agreement shall be interpreted to transfer a party’s nondelegable legal duties to another party or to eliminate any duty that cannot lawfully be waived. To the fullest extent permitted by law, I release the Released Parties from claims arising from risks I voluntarily assume under this Agreement, subject to the limitations expressly stated herein.

4. PHYSICAL CONDITION AND MEDICAL AUTHORIZATION

I represent that I am at least eighteen (18) years old, am legally competent to execute this Agreement, and am voluntarily participating in the Event. I acknowledge that I am responsible for determining whether my physical condition, training, fitness level, and health are adequate for participation. I understand that the Event may place substantial demands on my cardiovascular, respiratory, muscular, and skeletal systems. I agree not to participate if I am aware of a medical condition, injury, illness, or other circumstance that makes participation unsafe for me. I understand that the Organizer, Timing Provider, and City are not responsible for diagnosing my fitness for participation or providing individualized medical advice. In the event of an apparent medical emergency, I authorize Event personnel, emergency responders, or medical providers to arrange or provide emergency assistance as reasonably necessary, subject to applicable law and the judgment of the responding personnel. I understand that I am responsible for my own medical expenses, transportation, treatment, and insurance coverage, except to the extent applicable law provides otherwise or another party has expressly agreed to assume such expenses. I acknowledge that emergency assistance may be delayed, unavailable, or limited by circumstances beyond the Released Parties’ reasonable control.

5. PARTICIPANT CONDUCT AND COMPLIANCE WITH LAWS

I agree to follow all applicable laws, traffic regulations, race instructions, posted signs, course markings, safety directions, and reasonable instructions issued by authorized Event personnel, law enforcement officers, emergency responders, or other officials responsible for the Event. I will remain on the designated course, use designated crossings where required, yield as directed, and exercise reasonable care toward other participants, spectators, volunteers, motorists, and members of the public. I will not engage in reckless, abusive, threatening, disruptive, or unlawful conduct; intentionally interfere with race operations or timing equipment; use prohibited substances in a manner that endangers myself or others; or disregard a direction to stop, withdraw, or leave the course for safety reasons. I understand that failure to follow safety instructions may result in removal or disqualification from the Event without a refund, subject to applicable law and the Event’s published policies. I acknowledge that roads and public areas may remain accessible to authorized vehicles or members of the public unless otherwise lawfully restricted, and I will remain alert to changing conditions.

6. COURSE CONDITIONS, WEATHER, AND EVENT MODIFICATIONS

I understand that course conditions, traffic conditions, weather, attendance, public safety requirements, government directives, equipment availability, or other circumstances may change before or during the Event. The Organizer or other appropriately authorized officials may modify the course, adjust the start time, delay, suspend, cancel, or terminate the Event when reasonably considered necessary for safety, operational, legal, or emergency reasons. I agree to comply with such decisions and acknowledge that no particular course condition, weather condition, completion time, race result, or uninterrupted Event experience is guaranteed. To the fullest extent permitted by law and subject to any applicable published refund policy or other contractual obligation, I understand that Event modification or cancellation does not automatically entitle me to reimbursement of travel, lodging, equipment, registration, or other expenses. Nothing in this provision waives any refund right that cannot legally be excluded.

7. RACE TIMING, RESULTS, AND EQUIPMENT

I acknowledge that Pure Gold Athletics Corporation, doing business as Pure Gold Timing, provides official race timing, registration management, race-day check-in assistance, DJ service, on course water station set up, course setup equipment, and other specifically contracted services,  and may use electronic timing chips, bibs, mats, antennas, cables, computers, software, and other equipment. I understand that timing or results may be affected by equipment malfunction, interference, incorrect participant information, improper use or placement of timing devices, failure to cross designated timing points, or other technical or operational issues. Provision of these services does not make Pure Gold Timing the overall event organizer, traffic control authority, law enforcement provider, security provider, or emergency medical provider. Responsibility for overall event organization, road closures, permits, traffic management and public safety remains with the designated event organizer, the City of North Miami and applicable authorities, subjected to each parties obligation. To the fullest extent permitted by law, I release the Released Parties from claims arising from timing errors, delayed or unavailable results, scoring discrepancies, or technical interruptions, except to the extent liability cannot lawfully be waived. I agree to follow all timing instructions and acknowledge that official results may be subject to verification, correction, or the Event’s published dispute procedures. Nothing in this section releases liability for personal injury or other damages to the extent such a release would be unlawful.

8. PERSONAL PROPERTY AND EXPENSES

I understand that I am responsible for safeguarding my personal belongings, clothing, electronic devices, vehicles, and other property brought to or used in connection with the Event. To the fullest extent permitted by law, I release the Released Parties from claims for loss of or damage to personal property arising from risks associated with my participation or attendance, except to the extent such claims cannot legally be waived. I am responsible for my registration fees, travel expenses, lodging, medical expenses, and other personal costs associated with participation, subject to applicable law and any express written commitment by an Event entity.

9. INDEMNIFICATION AND RESPONSIBILITY FOR CLAIMS

To the fullest extent permitted by applicable law, I agree to indemnify and hold harmless the Released Parties from third-party claims, demands, damages, liabilities, judgments, and reasonable costs and attorneys’ fees to the extent arising out of my negligent, reckless, or intentional acts or omissions; my violation of applicable law or Event safety rules; my material breach of this Agreement; or injury to another person or damage to another person’s property caused by my conduct in connection with the Event. This obligation shall apply only to the extent permitted by law and to the extent the claim is attributable to my conduct. Nothing in this provision requires me to indemnify any Released Party for that party’s own negligence, gross negligence, reckless conduct, intentional misconduct, or other liability where such indemnification is prohibited by applicable law. This section does not create an obligation to indemnify a party merely because that party is named in a claim.

10. PHOTOGRAPHY, VIDEO, AND EVENT PUBLICITY

I understand that photographs, video recordings, and other media may be captured at the Event. I acknowledge that my image, likeness, voice, or appearance may appear in general Event photographs, recordings, news coverage, or factual Event documentation. I authorize such material to be used as promotional, advertising for the event on Social Media and websites from the Organizer, the City and Timing Provider. Nothing in this Agreement requires me to grant publicity rights beyond those lawfully authorized or otherwise applicable to the Event.

11. ELECTRONIC SIGNATURE AND ELECTRONIC RECORDS

I acknowledge and agree that this Agreement is presented and executed electronically through the Event registration website or another authorized electronic registration platform. By checking the applicable acknowledgment box and selecting the electronic signature, acceptance, or submission button, I intend to sign this Agreement electronically and to be legally bound by its terms to the same extent as if I had signed a paper document, to the extent recognized by applicable law. I acknowledge that my electronic signature may be associated with the information I submit, including my name, registration details, date and time of acceptance, and other electronic records maintained by the registration platform. I consent to the electronic delivery, storage, and retention of this Agreement and related records, subject to applicable law. I acknowledge that I have had the opportunity to read this Agreement before signing, that I may save or print a copy for my records, and that my failure to read it will not by itself invalidate my acceptance. I understand that my electronic acceptance is intended to constitute an enforceable agreement under applicable electronic-signature laws, including the Florida Uniform Electronic Transaction Act and, where applicable, the federal Electronic Signatures in Global and National Commerce Act.

12. VOLUNTARY AGREEMENT AND ACKNOWLEDGMENT

I confirm that I have read this Agreement carefully, understand its terms, and understand that it affects certain legal rights, including the right to bring certain claims against the Released Parties. I acknowledge that I am entering into this Agreement voluntarily and without coercion. I understand that I may decline to participate in the Event if I do not agree to its terms, subject to the Event’s registration and refund policies. I acknowledge that I have had the opportunity to ask questions and seek independent legal advice before accepting this Agreement. I intend for the assumption of risk, release, waiver, and other provisions of this Agreement to be binding upon me and, to the extent permitted by law, my heirs, executors, administrators, personal representatives, successors, and assigns.

13. GOVERNING LAW AND VENUE

This Agreement shall be governed by and construed in accordance with the laws of the State of Florida, without regard to conflict-of-law principles. Any legal action concerning this Agreement shall be brought in a court of competent jurisdiction in the State of Florida, subject to applicable venue rules, jurisdictional requirements, and any mandatory law governing claims against governmental entities. Nothing in this Agreement waives any governmental immunity, statutory protection, procedural requirement, or other defense available to the City of North Miami under applicable law.

14. SEVERABILITY AND INTERPRETATION

If any provision of this Agreement is determined by a court of competent jurisdiction to be invalid, unlawful, or unenforceable, that provision shall be limited or severed to the minimum extent necessary, and the remaining provisions shall remain in effect to the fullest extent permitted by law. No provision shall be interpreted to waive a right or release a claim that cannot legally be waived or released. Headings are included for convenience only and do not affect the interpretation of this Agreement.

15. NO ORAL MODIFICATION; ENTIRE AGREEMENT

This Agreement constitutes the agreement between me and the Released Parties concerning the assumption of risk, release, waiver, and related matters addressed herein in connection with my participation in the Event, and supersedes prior oral or written statements concerning those same matters to the extent permitted by law. Any modification must be made in a legally effective written or electronic record authorized by the relevant parties. Nothing in this Agreement modifies any separate agreement, permit, or contractual obligation among the Organizer, Timing Provider, and City, or limits rights or obligations that cannot legally be waived.

16. FINAL ACKNOWLEDGMENT AND ELECTRONIC ACCEPTANCE

BY CHECKING THE ACKNOWLEDGMENT BOX AND ELECTRONICALLY SIGNING BELOW, I CONFIRM THAT I AM AT LEAST EIGHTEEN (18) YEARS OLD, HAVE READ AND UNDERSTOOD THIS AGREEMENT, VOLUNTARILY ASSUME THE RISKS DESCRIBED ABOVE, AND AGREE TO THE RELEASE, WAIVER, AND OTHER TERMS TO THE FULLEST EXTENT PERMITTED BY LAW. I UNDERSTAND THAT THIS AGREEMENT INCLUDES A RELEASE OF CERTAIN CLAIMS ARISING FROM ORDINARY NEGLIGENCE TO THE EXTENT SUCH RELEASE IS LAWFUL. I UNDERSTAND THAT I AM GIVING UP CERTAIN LEGAL RIGHTS AND THAT MY ELECTRONIC ACCEPTANCE IS INTENDED TO BE LEGALLY BINDING.

By electronically accepting this Agreement, the Participant confirms that the information provided is accurate and that the Participant intends to be legally bound by this Agreement.

PARENT/NATURAL GUARDIAN WAIVER/CITY OF NORTH MIAMI - 5K TURKEY TROT 

Consent for a participant under 18 -  Florida Statutes § 744.301(3)

STATUTORY NOTICE AND PARENT/GUARDIAN CONSENT 

NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN

READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF FIRED UP ATHLETIC FORCE INC, AS RACE MANAGEMENT COMPANY, PURE GOLD ATHLETES CORPORATION DBA PURE GOLD TIMING, AND THE CITY OF NORTH MIAMI, FLORIDA, USE REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM FIRED UP ATHLETIC FORCE, PURE GOLD ATHLETES CORPORATION DBA PURE GOLD TIMING, AND THE CITY OF NORTH MIAMI, FLORIDA, IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND FIRED UP ATHLETIC FORCE, PURE GOLD ATHLETES CORPORATION D/B/A PURE GOLD TIMING, AND THE CITY OF NORTH MIAMI, FLORIDA, HAVE THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.

Important formatting requirement: The statutory notice below must remain entirely uppercase and be printed in a font at least five points larger than the rest of the waiver. 

MINOR CHILD PARTICIPATION WAIVER, PARENT/GUARDIAN CONSENT, ASSUMPTION OF RISK, AND RELEASE OF LIABILITY

Race/Event Name: City of North Miami Turkey Trot 5K

Race/Event Date: November 26,2026

Race/Event Location: North Miami City Hall / MOCA Plaza, 776 NE 125 Street, North Miami, Florida 33161

A. MINOR CHILD INFORMATION

Minor Child’s Full Legal Name: ______________________________________

Date of Birth: ___________________ Age: _______

Home Address: ___________________________________________________

City: __________________________ State: ______ ZIP: _______________

Emergency Contact Name: _________________________________________

Emergency Contact Phone: ________________________________________

B. PARENT OR NATURAL GUARDIAN INFORMATION

Parent/Natural Guardian’s Full Legal Name: ___________________________

Relationship to Minor Child: ________________________________________

Phone Number: __________________________________________________

Email Address: __________________________________________________

Address: _______________________________________________________

C. PARENT/GUARDIAN CONSENT

I am the parent, natural guardian, or legally authorized guardian of the minor child identified above. I represent that I have the legal authority to sign this document and grant permission for the minor child to participate in the race and its associated activities.

I voluntarily authorize the minor child to participate in the race, including applicable registration, check-in, warm-up, starting procedures, running or walking on the designated course, crossing the finish line, and related event activities.

I understand that participation in an organized running race is physically demanding and involves inherent risks, including risks that cannot be eliminated even when reasonable care is exercised.

I have read this document, understand its terms, and have had the opportunity to ask questions before signing.

ASSUMPTION OF RISK AND RELEASE

1. IDENTIFICATION OF RELEASED PARTIES

For purposes of this agreement, the following entities are collectively referred to as the “Released Parties,” to the extent permitted by applicable law:

1. Fired Up Athletic Force, in its capacity as race management company, together with its owners, officers, directors, employees, volunteers, representatives, and agents acting within the scope of their duties.

2. Pure Gold Athletes Corporation d/b/a Pure Gold Timing, together with its officers, directors, employees, representatives, and agents acting within the scope of their duties.

3. City of North Miami, Florida, together with its officers, employees, representatives, and agents acting within the scope of their duties.

The Released Parties are identified according to their respective roles in organizing, managing, timing, supporting, permitting, or facilitating the event. Nothing in this agreement is intended to enlarge any party’s legal responsibilities or waive any protection that cannot lawfully be waived.

2. DESCRIPTION OF INHERENT RISKS

I understand that running races and related athletic activities involve inherent risks of injury, illness, property damage, and death. These risks may exist before, during, and after the event and may arise from circumstances including, but not limited to:

· Falls, slips, trips, collisions, and contact with other participants, spectators, volunteers, or objects.

· Uneven, wet, slippery, damaged, or obstructed surfaces.

· Roadways, sidewalks, curbs, traffic, bicycles, vehicles, and other hazards along or near the course.

· Heat, humidity, dehydration, exhaustion, sun exposure, rain, lightning, and other weather conditions.

· Muscle strains, sprains, fractures, overexertion, breathing difficulties, cardiovascular events, and other physical injuries or medical emergencies.

· The physical condition, actions, negligence, or intentional conduct of other participants or third parties.

· Inadequate physical conditioning, failure to follow instructions, or failure to recognize personal physical limitations.

· Timing equipment, event structures, course markers, barriers, and other equipment or installations associated with the event.

· Delays in identifying or responding to a medical emergency.

· Other dangers that are characteristic of, intrinsic to, or an integral part of participation in a running race.

I understand that this list is not exhaustive and that additional risks may arise during the event.

3. ACKNOWLEDGMENT AND ASSUMPTION OF RISK

On behalf of myself and the minor child, to the extent permitted by law, I acknowledge and accept the inherent risks associated with the minor child’s participation in the event.

I understand that these risks may result in serious bodily injury, permanent disability, illness, property damage, or death, even if reasonable care is exercised by the event organizers or other persons involved.

I voluntarily authorize the minor child’s participation with an understanding of these risks.

4. STATUTORY WAIVER AND RELEASE ON BEHALF OF THE MINOR CHILD

Pursuant to section 744.301(3), Florida Statutes, and to the extent permitted by applicable law, I expressly waive and release, on behalf of the minor child, claims and causes of action against the Released Parties that would accrue to the minor child for personal injury, including death, or property damage resulting from inherent risks of participation in the event.

This release is intended to cover only those claims and risks that may lawfully be waived under Florida law, including the statutory authority applicable to commercial activity providers and their owners, affiliates, employees, and agents.

Nothing in this section is intended to release a claim that applicable law prohibits a parent or natural guardian from waiving in advance.

5. PARENT/GUARDIAN RELEASE OF PERSONAL CLAIMS

To the fullest extent permitted by applicable law, I, individually and in my personal capacity, release the Released Parties from claims I may have for personal injury, property damage, or other loss arising from the inherent risks of the minor child’s participation in the event, including claims for losses I personally sustain as a result of those inherent risks.

This paragraph does not waive any claim or right that cannot lawfully be waived in advance.

6. MEDICAL FITNESS AND EMERGENCY AUTHORIZATION

I represent that, to the best of my knowledge, the minor child is physically able to participate in the event and that I have considered any relevant medical conditions, limitations, or precautions.

I understand that it is my responsibility to determine whether the minor child should participate and whether medical advice is appropriate before participation.

In the event of an injury, illness, or medical emergency, I authorize event personnel to contact emergency services and facilitate reasonable emergency assistance for the minor child when necessary.

I understand that emergency medical care may involve additional costs and that the Released Parties do not guarantee the availability, timing, or outcome of medical treatment.

I agree to provide accurate emergency contact information and disclose relevant medical information when reasonably necessary for the minor child’s safety.

7. COMPLIANCE WITH EVENT RULES

I agree that the minor child will follow applicable event rules, safety instructions, course directions, traffic-control instructions, and reasonable directions given by authorized race personnel.

I understand that the organizers may remove the minor child from participation if event personnel reasonably determine that continued participation presents a safety concern or violates event requirements.

I acknowledge that the minor child must meet the event’s applicable age, registration, supervision, and participation requirements.

8. PERSONAL PROPERTY

I understand that the minor child may bring personal belongings to the event at their own risk.

To the extent permitted by law, I accept the inherent risks of loss of or damage to personal property associated with participation and attendance.

Nothing in this section releases a party from liability where such a release is prohibited by applicable law.

9. NO GUARANTEE OF SAFETY

I understand that event organizers, timing personnel, municipal authorities, and other event participants cannot guarantee that the course, event environment, equipment, or surrounding conditions will be free of hazards.

The existence of event rules, safety measures, course monitoring, timing services, or emergency procedures does not eliminate every inherent risk associated with running.

I understand that participation remains voluntary and that I may decline to authorize the minor child’s participation.

10. SCOPE AND LIMITATIONS OF RELEASE

This agreement is intended to be interpreted consistently with Florida law, including section 744.301(3), Florida Statutes.

The waiver and release provisions apply only to the extent that the relevant claims, persons, entities, and circumstances may lawfully be covered by a prospective release.

No provision of this agreement is intended to release liability where such a release is prohibited by law, create immunity that does not otherwise exist, or expand the legal authority of any party.

11. SEVERABILITY

If any provision of this agreement is determined to be invalid or unenforceable, the remaining provisions shall remain in effect to the extent they can be enforced consistently with applicable law.

Any invalid provision shall be limited or severed only to the extent necessary to comply with applicable law.

12. ACKNOWLEDGMENT OF UNDERSTANDING

I acknowledge that:

· I have read this agreement in its entirety.

· I understand the nature of the event and the risks associated with participation.

· I understand that this agreement includes a waiver and release of certain claims on behalf of the minor child and certain personal claims I may have.

· I have had the opportunity to seek independent legal advice before signing.

· I am signing voluntarily and have not relied on any promise or representation that is inconsistent with this written agreement.

· I understand that I may refuse to sign this agreement and that the event organizers may refuse to permit the minor child to participate if I do not sign.

· 

13. GOVERNING LAW

This agreement shall be governed by the laws of the State of Florida, subject to applicable federal law and any mandatory legal requirements.

14. PARENT/NATURAL GUARDIAN SIGNATURE

I certify that the information provided in this agreement is accurate and that I am legally authorized to consent to the minor child’s participation and execute this agreement on the minor child’s behalf.

Minor Child’s Full Legal Name: _____________________________________________________

Parent/Natural Guardian’s Printed Name: _____________________________________________

Parent/Natural Guardian’s Signature:_________________________________________________

Date Signed: ______________________ Time: ______________

Relationship to Minor Child: __________________________________