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Contact Information & Waiver Form

2010– 2011

Contact Parent/Guardian Name:                                                             2nd Parent name:                                  

Street:                                                         Town:                                      Zip:                     

Home Phone:                                              Cell Phone:                                                         

              Please check here if you would like to be included in our KKO directory

How did you hear about us?                                                                                                  

Emergency contact name:                                                         Phone Number:                                                  

*E-mail address:                                                                                                                   

*We keep all members updated by email; please supply the most currant email address you would like us to use.

Also, add KellyOsterNY@aol.com to your address book so you can receive our emails

Family Name:                                             

 Child’s Allergies:                                                                                   Asthmatic?  Yes             No  

Other Medical Conditions:                                                                                                       

I acknowledge that this activity involves exertion and carries with it the potential for injury.

I hereby agree to waive the right to take legal action against the Kelly-Oster School, Carmel VFW,

Putnam Valley German-American Club, Shenorock HOA, Kerry Kelly-Oster, Karyn Oster,

and/or any affiliates and associates for injuries incurred on these premises. It is understood

and agreed that the participant is physically fit and prepared for participation in the activities which will be

undertaken, and that the participant has not been advised by any doctor or other medical person that

participation in these activities should be avoided and/or limited.

I agree to make payments on time (10/1/10& 2/1/11) and understand I will be charged a $25 late fee.

I also understand there is no refund once payment has been made.

Parent/Guardian Signature:                                                             Date: