ADVENTURE SUMMER PROGRAM 2009 REGISTRATION
FORM
Please enroll my child for:
( )Session 1 (7/6-7/10)R#
______( )Session 2
(7/13-7/17)R#______( )Session
3 (8/3-8/7)R#______
R#
= Office use only
NAME____________________________________________AGE_____DATE
OF BIRTH________________
ADDRESS_________________________________________________________PHONE________________
SCHOOL ______________________________
GRADE THIS FALL ____________________ M/F_________
PARENT/GUARDIAN:
NAME___________________________________________________________________________________
ADDRESS___________________________________________________PHONE______________________
TRANSPORTATION:
METHOD
TO/FROM: ________________________
by NAME _____________________________________
RELATION
________________________________________ PHONE ________________________________
IF
PARENT IS NOT AVAILABLE IN AN EMERGENCY, PLEASE NOTIFY:
EMERGENCY CONTACT ____________________________________
Relationship___________________
ADDRESS________________________________________________________________________________
HOME PHONE _________________________________
WORK PHONE______________________________
Permission/ Emergency Treatment
I hereby give permission for my son/daughter to
participate in the
Jaffrey
Parks
and Recreation Department Program. I assume all
risks and hazards incidental to such participation, including transportation to
and from activities, and I do hereby waive, release and agree to hold harmless
the said Town, its volunteers, staff and all sponsors for any claim arising out
of injury to my son/daughter of property damage that might occur during
participation. I am aware of the hazards of the sport and the risk of injury in
the athletic program.
In case of emergency I hereby give permission to the program staff and medical
personnel selected by the Recreation Department and staff, in my absence, to act
as my agent to apply simple first aid when necessary or in the event of a more
serious accident, for my child to be transported to an emergency medical
facility to receive medical treatment. I also authorize the medical personnel to
administer such treatment as is medically necessary and I authorize the hospital
to undertake examination and emergency treatment if warranted on behalf of my
child. EVERY EFFORT WILL BE MADE TO CONTACT PARENTS IN THE EVENT OF AN EMERGENCY
In an effort to further promote the department
activities, on occasion photos or video may be taken of you or your children. By
signing bellow, you are giving us permission to use these images for the
purposes of Jaffrey Recreation Department promotional material.
Parent Signature
Date
**************************PLEASE
COMPLETE HEALTH RECORD ****************************
