A.I.M. SUMMER PROGRAM 2009 REGISTRATION FORM

Please enroll my child for:

Session 1    3 day (  )  5 day (  )  EC(  )   R#______ Session 5    3 day (  )  5 day (  )  EC(  )   R#_____
Session 2    3 day (  )  5 day (  )  EC(  )   R#______ Session 6    3 day (  )  5 day (  )  EC(  )   R#_____
Session 3    3 day (  )  5 day (  )  EC(  )   R#______ Session 7    3 day (  )  5 day (  )  EC(  )   R#_____
Session 4    3 day (  )  5 day (  )  EC(  )   R#______ Session 8    3 day (  )  5 day (  )  EC(  )   R#_____
EC=Extended Care      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 AIM:   _________________________ 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 **************