2. 
3. Prince George’s County Government
   Department of Public Works and Transportation
   8400 D’Arcy Road
   Forestville, Maryland 20747
   
   SPECIALIZED ACTIVITY PERMISSION SLIP
   & WAIVER OF LIABILITY FORM
   (For all participants below 18 years old)
4. 
6. Name of Activity
   Growing Green With Pride Event
8. Name*
9. Age*
11. Name of Parent/Guardian*
13. Phone Number : Home (H)
14. Work (W)
15. Cell (C)
17. Address
19. City
20. State
21. Zip Code
23. Emergency Contact(s)*
25. Phone Number : Home (H)
26. Work (W)
27. Cell (C)
29. Please list any allergies, special needs
31. Pictures of the participant during the event may be published*

    1. Yes

    1. No
33. RELEASE OF LIABILITY & PARENT/GUARDIAN’S AGREEMENT/AUTHORIZATION/RELEASE
    I understand and acknowledge that participation in the above listed activity is purely voluntary, and participants should not participate in any activity beyond their physical, mental, and/or medical capacity. By way of this form, I authorize the organization coordinator or staff of Prince George’s County, Maryland Government to obtain medical/hospital treatment for the above participant in the event of an emergency.
    
    I hereby and represent that the participant is a minor, I am his/her parent/guardian and authorized to provide releases, authorizations, and permissions stated herein and all the information provided is accurate and complete. I hereby give permission for the participant named above to participate in the Prince George’s County, Maryland event.
    
    I, individually and on behalf of my minor child, for any and all heirs and personal representatives, do hereby release and forever discharge Prince George’s County, Maryland, as well as its agents to include but not limited to Directors, Officers, Employees, Agents, Principals, Attorneys, and Successors and all persons acting by, through, under or in concert with any of the aforementioned from any and all claims, obligations, debts, demands, actions, causes of action, suits, accounts, covenants, contracts, agreements, and damages whatsoever of every name and nature, both in law and equity, which I now have or in the future may have relating to, occurring during, or arising out of, any injury sustained by me or my child/ward, as a result of his/her participation in the Specialized Activity named above.
    
    Please read carefully and in its entirety. This specialized activity permission slip and release of liability contains a release of known and unknown claims by you. By signing below, I acknowledge that I have read and understand this release of liability, and knowingly and voluntarily sign below:
35. Signature Of Parent Or Guardian
36. Date
    Date
38. Print Name Of Parent Or Guardian
Leave This Blank:


39. Print Only

* indicates a required field