Junior Participant Details

Parent / Legal Guardian Details

Medical / Safety Disclosure

Does the Junior Participant have any medical condition, injury, allergy, medication, restriction or other matter Revive should know about before participation? YES / NO

Photo / Video Consent

I give Revive Wellness + Recovery permission to photograph/video the Junior Participant and use those images for marketing and promotional purposes: YES / NO

Declaration and Signature

I confirm that I am the parent/legal guardian of the Junior Participant named above (or otherwise have lawful authority to provide this consent), and I consent on the Junior Participant's behalf to the terms, acknowledgements and participation described in this Agreement.