liability form, FORM 3

 
 

FORM 3
GLOW Homeschool group of Johnstown

     Liability Waiver for Group activities

                      This must be signed and turned in with your application

I do hereby certify that I and my family are covered by our own medical insurance policy. I

understand and agree that neither GLOW Johnstown Homeschool Group, nor the facilities 

in which group activities are held, shall be liable for personal injuries incurred by me or my 

children while participating in a GLOW Johnstown Homeschool Group event or activity. I 

also agree not to hold any staff, instructors, coaches, field trip coordinators, or any other 

person(s) liable for any personal injuries incurred by me or my children while participating 

in GLOW Johnstown Homeschool Group events and activities.

________________________________________________________________

Medical Insurance Carrier Policy Number

______________________________________________________________________

Print Father’s Name                                                         Print Mother’s Name

______________________________________________________________________

Father’s Signature Date Mother’s Signature Date

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For Office Use Only - Don't fill out!

School Year:                                        Date Received:

Type of Membership: Full Year / Half Year (Jan to June)

Paid: Check Cash M.O. Amount: ______________ Ck # ________________

Email Added: _____ Membership Email sent: _____ Facebook Email sent: _____