BestHealth Kids Application Form

BESTHEALTH KIDS APPLICATION FORM

Print, complete and mail to: BestHealth, PO Box 30339, Winston-Salem, NC 27130

1^st Child:	2^nd Child:
Name: _________________________	Name: _________________________
Gender: _____ Male _____ Female	Gender: _____ Male _____ Female
Date of Birth: ______/______/______ Month / Day / Year	Date of Birth: ______/______/______ Month / Day / Year

3^rd Child:	4^th Child:
Name: _________________________	Name: _________________________
Gender: _____ Male _____ Female	Gender: _____ Male _____ Female
Date of Birth: ______/______/______ Month / Day / Year	Date of Birth: ______/______/______ Month / Day / Year

PARENT / GUARDIAN’s NAME: _____________________________________________________________

ADDRESS: ______________________________________________________________________________

CITY: _________________________________________ STATE _____________ ZIP __________________

DAY PHONE: __________________________________ EVENING PHONE: ___________________________

RELEASE STATEMENT
I wish to enroll my child(ren) listed above in BestHealth Kids, a free club for children ages 12 and under with a focus on health and safety. I agree that my child(ren) will be accompanied by me or another responsible adult at all times during which they are participating in BestHealth Kids. I realize that my child(ren)’s participation in BestHealth Kids activities may involve some risk. Therefore, in consideration of the Sponsors allowing them to participate in BestHealth Kids and to use their services and facilities, I hereby waive and release the Sponsors, and their employees, agents, representatives, officers, merchants, directors and trustees for any and all liability for any injuries, losses, damages, claims and expenses, including reasonable attorney’s fees, arising out of or related to my child(ren)’s participation in BestHealth Kids

______________________________________ ___________________________
Signature Date

CONSENT TO PHOTOGRAPH
I hereby grant full permission to any and all of the Sponsors of BestHealth Kids to use my and my child(ren)’s name(s), photograph, videotape, motion picture, recording or any other record of this event/activity for any legitimate purpose, without compensation or further approval

______________________________________ ___________________________
Signature Date

Sponsors of BestHealth Kids: Hanes Mall Merchants Association; JG Winston-Salem, LLC; CBL & Associates Properties, Inc.; CBL & Associates Management, Inc.; CBL & Associates Limited Partnership; CBL Holdings I, Inc.; CBL/JI, LLC; Brenner Children's Hospital & Health Services; Wake Forest University School of Medicine; North Carolina Baptist Hospital; Wake Forest University Baptist Medical Center.