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Participant Information Sheet First Middle Last Name Initial Name Date of Address Birth City State Zip 2nd 2nd Phone # Phone # Phone # Description ♦ Emergency Contact #1 Relation Name Phone # ♦ Emergency Contact #2 Relation Name Phone # ♦ Doctor/Hospital Name Phone # ♦ Special Medical Info I am fully aware of the fact that there are special dangers and risks inherent in participating in the Puyallup Senior Center Trip Program, including the risk of serious physical injury, death or other consequences that may arise or result directly or indirectly from my participation. Being fully informed as to these risks and in consideration of being allowed to participate in these activities, I hereby assume all risk of injury, damage and liability arising from such activities or use and hereby release the City of Puyallup, its officials, employees and agents and waive any right of recovery that I may have to bring claim or lawsuit against them for any personal injury death or other consequences occurring to me aris- ing out of my voluntary participation in this senior citizen activity or program. Today’s Date Participant’s Printed Name Participant’s Signature Emergency Contact/Medical Information Personal Contact Information Print Form