Event Sponsor: Dobyns Bennett Quarterback Club


I the undersigned parent or guardian, hereby consents to my child,

to participate in activities connected with the senior picnic sponsored by Dobyns-Bennett Quarterback Club, Thursday, July 19, 2018. I certify that my child is able to participate in these activities, including water sports, and other activities associated with the picnic (unless otherwise indicated). If there are any activities I do not want my child to be involved in, I have listed them below.

If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them below. In the event an emergency occurs, I may be reached at the telephone number below. If I cannot be reached within a reasonable period of time, I hereby authorize an adult volunteer leader to make emergency medical decisions for my child. I assume full financial responsibility for any costs connected with such medical treatment and I release Joseph and Kim DeStefano as well as the Dobyns- Bennett Coaches and the Dobyns-Bennett Quarterback Club, its officers, directors, agents employees and volunteer leaders of any liability or cost as pertaining to named child, included in this release.


I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do hereby agree to hold Ridgefields Country Club and the Dobyns-Bennett Quarterback Club, its officers, directors, agent’s employees and volunteer leaders harmless from any and all liability actions, causes of actions, claims, expenses, and damages on account of injury or illness to my child or property, even injury or illness resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities listed below.


I expressly agree that this release, waiver and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Tennessee and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.


I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.

Parent or Guardian Signature (consent to participate and agree all above information is correct) *
Powered byFormsite