Form Center

2. TITANS OBSTACLE COURSE ENTRY FORM

   Saturday, August 5th, 2023 | 9am - 12pm | Jacksonville's Farmer's Market Pavilion

4. Parent's Name/Legal Guardian*
6. Participant's Name*
7. Participant's Date of Birth*
8. Age*
10. Address*
    Address
11. City*
13. State*
14. Zip*
15. Phone Number*
17. E-mail*
19. Waiver

    LIABILITY/PHOTO RELEASE AGREEMENT & CONSENT FOR MEDICAL TREATMENT OF A MINOR: I hereby release and forever discharge the Jacksonville Parks & Recreation Department, the City of Jacksonville, and their employees from any and all manner of claims, causes of action, or liability, which may exist or may exist at any time in the future, arising out of or pertaining to any injury, loss, damage, or harm of any kind which has, will or may result or occur while participating in this program. As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or wellbeing of my dependent. I hereby consent to the use, reproduction, editing, and/or broadcast by the City of Jacksonville, Arkansas of any and all photographs, video recordings, and audio recordings of me and/or my family, taken by or on behalf of the Jacksonville Parks & Recreation department, without any compensation to me. All negatives and positives prints video-recorded images and audio recordings shall constitute the property of the City of Jacksonville solely & completely.

21. Waiver Agreement*
    -- Select One --YesNo

25. If you have any questions contact the Events/Marketing Department @ 501-982-4171 or Email www.JacksonvilleParks@gmail.com

    
    

    
    

    
    

Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

* indicates a required field