PAK NMSC

Name *

Email *

Phone Number *

City

Child's Age

Are You An Existing Patient?

Select a Date in Kingston or Clarks Summit *

Friday, Sept 27th @ 11:00 AM in Kingston

Friday, Sept 27th @ 11:00 AM in Clarks Summit

Friday, Oct 25th @ 11:00AM in Kingston

Friday, Oct 25th @ 11:00AM in Clarks Summit

Friday, Nov 15th @ 11:00AM in Kingston

Friday, Nov 22nd @ 11:00AM in Clarks Summit

Friday, Dec 20th @ 11:00AM in Kingston

Friday, Dec 27th @ 11:00AM in Clarks Summit

Additional Comments

As the individual and on behalf of minor, personal representatives and my heirs, I hereby voluntarily agree to release, waive, forever discharge, hold harmless, defend and indemnify PAK and their agents, officers, boards, volunteers and employees from any and all liability and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my participation in activities related to the event. I also hereby grant permission for PAK to publish images of activities and of me for the purpose of promoting PAK. On behalf of the participant and minor, individually, the undersigned parent(s) and/or legal guardian(s) for the minor participant executes this Waiver and Release. If, despite this release, the participant makes a claim against PAK, the parent(s) and/or legal guardian(s) will hold PAK and or it’s employees harmless for any injury, claim, monies, sanctions. I grant the permission freely without reservation.

Confirmation *

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