NERO INTERNATIONAL HOLDING COMPANY

	What's Your Story?

Proud Sponsor of

Joseph Valenti
NERO GA LARP Park
653 Country Kitchen Rd.

Barnesville GA 30204

(914) 309 - 7718

E-mail: NERO HQ

AIM: neroint

NERO INTERNATIONAL HOLDING COMPANY, INC.
LEGAL GUARDIAN MINOR PLAYER RELEASE FORM

NERO®
P.O. Box 543
Rye NY 10580-0543
(914) 328-9123
www.NeroLarp.com

Printed Name of Parent or Legal Guardian: _____________________________

Guardian Home Telephone: _______________________________________

Guardian Backup Telephone: _____________________________________

Name of Member: _____________________________________

Member Age: _______________ DOB: ________________________

Member Address: ____________________________________________

Member Insurance Provider: ___________________________________

Members Insurance Policy Number:___________________________________

Member Pediatrician Name: _______________________________________

Member Pediatrician Telephone:________________________________

Members Known Allergies: __________________________________________

Members Medications: _______________________________________

Any Limitations: _____________________________________________________________________

Specific Comments: ___________________________________________________________________

____________________________________________________________________________________

I, _____________________________, parent/legal guardian of _____________________________,

do hereby assign temporary legal guardianship to ______________________________ for this NERO ® event,

dated _______________ to ________________.

I, ______________________________, parent/legal guardian of _____________________________,

do hereby release NERO® and its affiliates from medical liability and will not hold NERO ® responsible for any accidents that my son/daughter has while attending an event.

I _______________________________, parent/legal guardian of ___________________________,

do hereby give permission for ________________________, to be taken to the nearest hospital, and/or receive emergency medical treatment, if necessary.

Signature of Parent / Legal Guardian: __________________________________________ Date:___________

Printed Name of Parent / Legal Guardian: _______________________________________

Terms & Conditions Web Site Comments / Suggestions

NERO® is the Registered Trademark of NERO International Holding Co., Inc. USPTO registration number 2,270,409
Unauthorized use of the NERO Name, NERO Logo, NERO Rule Book© or NERO Game System© is strictly prohibited.