MINIS SUMMER FUN 2009  REGISTRATION FORM

Runs daily each week from 8:30 am until 12:30 pm

  Please enroll my child for:

(   )   Session 1  (7/6-7/10)   R#                            (   )   Session 4  (7/27-7/31) R#                   

(   )   Session 2  (7/13-7/17) R#                            (   )   Session 5  (8/3-8/7)                 R#                   

(   )   Session 3  (7/20-7/24) R#                       

 R# = Office use only

  NAME_____________________________________________ AGE _____DATE OF BIRTH________________

  ADDRESS__________________________________________________________PHONE________________

  M/F_______Any special needs:________________________________________________________________

  PARENT/GUARDIAN:

  NAME____________________________________________________________________________________

  ADDRESS______________________________________________________PHONE____________________

  TRANSPORTATION:

  METHOD TO/FROM MINIS:   _________________ 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****************************