Child's Name	Age
Child's Name	Age
Child's Name	Age
Child's Name	Age
Accompanying Teen/Adults
Address
Daytime Telephone	Amount Enclosed
Date

AGREEMENT TO RELEASE ASSUMPTION OF RISK AND AGREEMENT TO HOLD HARMLESS

This statement must be signed in order for your registration to be processed!

The undersigned is aware that there are certain inherent risks involved in the Fairlington Halloween Party including but not limited to the risks of theft or of damage to my property, and the risk involved in participating in recreation activities. In consideration of my being granted permission to participate in these activities and to use the facilities of the County and/or other activities and services provides the Arlington County Department, of Parks, Recreation and Community Resources, its agents and employees, including food service, I, on behalf of myself, my executors, administrators, heirs, next of kin, and successors, hereby covenant to hold harmless and indemnify the County and all of its officers, departments, agencies, agents and employees from any and all claims, losses, damages, injuries, fines, penalties and costs(including court costs and attorneys fees), charges, liabilities, or exposure, however caused, resulting from or arising out of or in any way connected to me or my families participation in the Fairlington Halloween Party.

I, ________________________________have read and understand the HOLD HARMLESS AGREEMENT and by my signature agree to its terms.

SIGNATURE ___________________________________________DATE _________________________