2. Child's Name*
3. Birth date*
   Birth date
5. Parent or Guardian*
6. Phone Number*
8. Address*
10. City*
11. State*
12. Zip*
14. Please list any health concerns, including allergies) Food or other) or disabilities that we should be aware of.
    If there are listings in this section please contact the Rutledge-Wilson Farm Community Park prior to the program. The concerns listed on this form in no way limit your child’s participation in this program.
16. My family and I hereby waive and release the Springfield-Greene County Park Board and its representatives from claims of damages and/or injuries incurred while participating in or as a spectator of the Springfield-Greene county Park Board activities.
17. Parent/Guardian Electronic Signature*
    Please type your First and Last Name
19. I give my permission for me and/or my child to be photographed while participating in Park Board activities, and to use any photographs of me and/or my child for Park Board promotional purposes
20. Parent/Guardian Electronic Signature*
    Please type your First and Last Name
22. I will allow the following authorized person(s) to pick up my child,
23. Child's Name*
25. from programs at Rutledge-Wilson Farm Park. Only the following authorized person(s) will be permitted to pick up my child unless park staff has been notified with written notice. I understand that the authorized person(s) listed will be required to show a photo ID when picking up my child.
27. List Authorized Person(s)
29. Parent/Guardian Electronic Signature*
    Please type your First and Last Name
30. Date*
    Date
32. 1. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Release Form.
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field