Kidz Pacz Participation Form Parent/Legal Guardian Email Phone number Street Address Apt no. City Zip Code Child 1's Name Child 1's Age Child 1's Age Child 1's Ethnicity/Race Child 2's Name Child 2's Age Child 2's Ethnicity/Race Child 3's Name Child 3's Age Child 3's Ethnicity/Race Child 4's Name Child 4's Age Child 4's Ethnicity/Race Child 5's Name Child 5's Age Child 5's Ethnicity/Race Child 6's Name Child 6's Age Child 6's Ethnicity/Race In an emergency please contact: Emergency Contact Name Emergency Contact Phone Emergency Contact Relationship I certify to Galveston County Food Bank (“GCFB”) that I am the parent/legal guardian of the children named above (“my children”); I agree to allow my children to participate in the Summer 2019 Kidz Pacz Program (“Program”) by receiving KIDZ PACZ provided by the Galveston County Food Bank to a designated host site. I agree that we will follow all rules of the Program and of the host site, and that GCFB may at any time change, suspend or terminate the Program; I understand that GCFB is not responsible for and does not control the host site, and does not represent the safety or condition of the host site. I understand that for children with food allergies, Kidz Pacz items may contain possible allergen-containing ingredients that could be harmful to them. Parents and guardians concerned with food allergies need to be aware of this risk; I agree that GCFB does not assume any liability for adverse reactions to foods consumed, and I agree to assume any and all risks associated with my children’s participation in the Program, including any adverse reaction my children may have to foods consumed. I, FOR MYSELF AND MY CHILDREN, HEREBY RELEASE AND HOLD HARMLESS GALVESTON COUNTY FOOD BANK FROM ALL LIABILITY, CLAIMS, DAMAGES, COSTS, ACTIONS AND SUITS IN ANY WAY DIRECTLY OR INDIRECTLY RELATED TO OR ARISING OUT OF THE PROGRAM OR MY CHILDREN’S PARTICIPATION IN THE PROGRAM, INCLUDING BUT NOT LIMITED TO ANY ILLNESS OR INJURY TO MY CHILDREN, (“LIABILITIES”), EVEN IF SUCH LIABILITIES ARISE IN WHOLE OR IN PART FROM THE SOLE, JOINT OR CONCURRENT NEGLIGENCE OF GCFB. *This institution is an equal opportunity provider. Sign & Submit
