I Do Have Insurance

KD Entertainment
Indiana Fear Farm
Jamestown, Indiana

INSURANCE VERIFICATION

We, the parents or guardians of minors listed below have insurance with provider listed below that will pay the medical or surgical expenses that result from any injury, major or minor, that the above- named volunteer may receive as a result of participating in a scheduled event at/for KD Entertainment/Indiana Fear Farm. This insurance will also cover the above-named volunteer while to or from the scheduled events. Since we, the parents or guardians of the above-named volunteer have an insurance policy which will provide adequate financial coverage for any type injury or injuries or whatever might result, we, the parents or guardians agree to release KD Entertainment/Indiana Fear Farm or any part thereof, from any obligation as pertains to financial responsibility in these matters for the events this year or any period thereafter.

Permission for Medical Treatment

In the event of an emergency requiring medical attention, I hereby grant permission to a physician or other hospital personnel designated by KD Entertainment/Indiana Fear Farm staff to attend to my son/daughter.

I expect every effort will be made to reach me before any treatment or hospitalization is undertaken.

Who will be participating?

Adult Children

Signee Information

First Name *

Last Name *

Your Date of Birth *

Phone *

Address *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Insurance Information

Insurance Company*

Policy Number*

Emergency Contact

** Emergency Contact info should be different from your own if adult or parents' info if filling out for minor. **

Emergency Contact Name*

Relationship*

Emergency Contact Address

Address, City, State, Zip

Emergency Contact Cell Phone*

Emergency Contact Work Phone

PLEASE USE THE AREA BELOW TO LIST ANY ADDITIONAL INFORMATION YOU FEEL WE SHOULD KNOW ABOUT YOU OR YOUR CHILD IF FORM IS FOR A MINOR:

Sign Here

By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.

I Do Have Insurance

Who will be participating?

Signee Information

Insurance Information

Emergency Contact

Please enter participants' full names: