Liability Waiver/Permission Slip

Child's Information

Tell us about the person participating

Emergency Contact Info

  • Child/Guardian
  • Emergency
  • Waiver

Child's and Guardian Info

Child's Name

Address, City, State, Zip

Child's Phone

Child's email

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian email

Emergency Contact Info

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relation to Child


Event where the child is participating

Liability Waiver: I am aware that participation in the above-mentioned event has some inherent risks and injury that can occur. On rare occasions, these injuries can be serious. In consideration of my child being allowed to participate in the My Grandma’s House event, I, the parent/guardian, assume the risk of all injury and agree not to hold My Grandma’s House, the directors, staff, coordinators, volunteers liable for any harm or damage caused to my child resulting from his/her participation in any My Grandma’s House events or activities. By signing this waiver, I also authorize the use of pictures of the above-named participant to be posted on the My Grandma’s House website and social media outlets pertaining to the event.

Do you agree to the waiver above?

eSignature - Type your name here

Todays Date

To confirm the receipt of this waiver/permissions form, have the parent/guardian of the participating child contact Cynthia Erickson via phone (907-750-9123) or email (