MILITARY FAMILY MONTH 2012 JOINT BASE LEWIS-MCCHORD FAMILY TREASURE HUNT REGISTRATION FORMPlease complete and return registration and release of liability forms to the Family Resource Center (FRC), Installation Volunteer Corps Office, FRC Bldg 4274, 9th Division & Idaho Avenue, JBLM no later than 4:30 p.m., 31 October 2012FAMILY NAME:______________________________________________________________PARTICIPATING FAMILY MEMBERS (must list names and ages - individuals must be animmediate family member) Name Age 1.____________________________________ ___________________ 2.____________________________________ ___________________ 3.___________________________________ ___________________ 4.____________________________________ ___________________ 5.____________________________________ ___________________ADDRESS: ___________________________________________________________________CITY: ____________________________ STATE: _________ ZIP:___________________PHONE: ____________________________ ALTERNATE: _________________________E-MAIL ADDRESS**: _____________________________________________________**Confirmation of receipt of your entry form will be sent to your email address.SPONSOR’S UNIT: ____________________________________________________________I agree to all terms outlined in the Joint Base Lewis-McChord Family Treasure Hunt Rules. Ialso agree to be interviewed and/or have my picture taken for FRC websites and/or theNorthwest Guardian Newspaper use publicizing the event (not all participants will be askedfor interviews/photos).__________________________________________ ______________________________Adult Team Member Signature Date__________________________________________ ______________________________FRC Staff Member Signature Date Received
PLEASE ENSURE LIABILITY RELEASE FORM IS ATTACHED AND SIGNED. RELEASE OF LIABILITY Data Required by the Privacy Act of 1974Prescribing Directive: 10 USC 2733, 28 USC 2671-2680, AR 27-20Authority: Title 10, USC 3012. Principal Purposes: To release the United States Government, Department of the Army, I Corps andGarrison Command, Joint Base Lewis-McChord, and the agents and employees thereof from any and all liability arising from orincident to participation in the Joint Base Lewis-McChord Family Treasure Hunt.Mandatory or Voluntary Disclosure and Effect on Individual Not Providing Information: Voluntary; however, if information is notprovided, participation in the Joint Base Lewis-McChord Family Treasure Hunt may be denied.********************************************************************************************* In consideration of the permission extended to me by the United States, through its agents, toparticipate in the Joint Base Lewis-McChord Family Treasure Hunt, I , and the below listed members of my immediate family, agree to releaseand hold harmless the United States Government, the United States Army, Joint Base Lewis-McChordand the agents and employees thereof from any and all liability for personal injury, death, propertydamage or loss, or any other loss resulting from or arising out of my participation in the Joint Base Lewis-McChord Family Treasure Hunt. Participation in the Joint Base Lewis-McChord Family Treasure Hunt includes, but is not limited tothe risk of death or serious injury such as driving to/from various locations on Joint Base Lewis-McChordand in the local area, or the conduct of other participants, including their negligence or willful misconduct. I certify that I will abide by all safety rules and the direction of the Joint Base Lewis-McChordFamily Treasure Hunt coordinator. I further acknowledge that failure to abide by all safety rules and thedirection of the Family Resource Center staff may result in my being disqualified from participating in theevent and forfeiting eligibility for event prizes. I also agree to release the United States and the United States Army, Joint Base Lewis-McChordand the agents and employees thereof from any and all liabilities, claims, and causes of action, based onor arising from negligence or gross negligence on the part of the United States Army, Joint Base Lewis-McChord, and its agents and employees. I acknowledge that I have read and understand the provisions of this release and understand thatit is binding upon myself and my assigns, heirs, executors, beneficiaries, family members, and derivativeclaimants. I further acknowledge that I have no medical history or condition that would preclude me fromparticipating in the Joint Base Lewis-McChord Family Treasure Hunt.Printed Name of Participant DateSignature of Participant*Participant listed above must be the parent/legal guardian of those family members listed below:Printed Name of Family Member Participant Printed Name of Family Member ParticipantPrinted Name of Family Member Participant Printed Name of Family Member ParticipantPrinted Name of Family Member Participant Printed Name of Family Member Participant This original signed two page registration form must be hand-carried to the Family Resource Center by deadline date.