KENTUCKY DEPARTMENT OF PARKS

WAIVER OF MINOR’S LIABILITY CLAIMS

Park Name: __________________________________________________

Event: __________________________________________________

Date of Event: _______________ _____, 2012

I, _______________________________, the undersigned parent or guardian of

__________________________________ (name of minor), DOB ___________ (date of birth of minor),

do hereby consent for him/her to participate in ______________________________ (name of

 activity) at ______________________ (name of state park) on ________________ _____, 2012 (date of activity).

 In case of an accident or injury to my child, I authorize my child to be treated by a medical professional and/or to be given or provided such emergency medical care as may be required. My medical insurance carrier and ID No. and/or Social Security No. are ________________________________________________________. My child’s physician is Dr.

_______________________.

 I hereby covenant, promise and agree for my minor child, myself, my personal representatives, heirs and next of kin, that neither the Tourism, Arts and Heritage Cabinet, Kentucky Department of Parks, nor ____________________________ (name of state park), any of its agents, officers or employees shall be held responsible or liable for any negligence, implied or otherwise, for personal injury or damages suffered or sustained by my minor child in connection with, arising out of, or resulting from any and all activities associated with the abovementioned event.

______________________________________________________________________________
Parent or Guardian Name (Please Print)

______________________________________________________________________________
Parent or Guardian Signature                            Date

______________________________________________________________________________
Witness Name (Please Print)

______________________________________________________________________________
Witness Signature                                     Date