Light and Fire Registration Form

Student Name

First NameMiddle NameLast Name

Birth Date

MonthDayYear

Race/Ethnicity

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Highest Degree Earned

Student E-mail

example@example.com

Mobile Number

Format: (000) 000-0000.

Phone Number

Format: (000) 000-0000.

Work Number

Format: (000) 000-0000.

I am part of the blanksfire department.

Waiver

Southeastern Illinois College&#13;&#10;Light and  Fire Course&#13;&#10;Medical Release/Waiver Form&#13;&#10;Being the student or  parent or legal guardian of the person on the registration,&#13;&#10;I hereby give my permission for the student named above to participate in the event known as Light and  Fire course and hereby voluntarily RELEASE AND FOREVER DISCHARGE AND HOLD HARMLESS Southeastern Illinois College, its instructors, volunteers and/or sponsors of the event against any and all claims, demands, damages, expenses, causes of action or liability of any kind whatsoever, that said child, his/her next of kin, heirs, guardians, representatives or assigns, may have for personal injury, bodily injury, or property damage arising from participation in and/or observation of activities of the event. It is my intent that no claim of any person or entity through my child, me or my guests, or any claims of any person or entity against me or my guests shall ever cause Southeastern Illinois College, its instructors, volunteers and/or sponsors of the event to incur any expense of any kind whatsoever.&#13;&#10;Photograph/Media Release: All college activities may be recorded & video recorded for college purposes. Entry into campus grounds & buildings constitutes consent to be photographed or videotaped for college purposes.&#13;&#10;&#13;&#10;

Signature

SIC Light and Fire Registration