Youth Program Registration Form

Please print and fill out this form completely. It will remain on file and be updated on a yearly basis. If all pertinent information is the same, multiple children may use one form. However, please list them by individual name, M/F and DOB. Thank you

Childs Name                                                                 M/F     DOB                                         
Childs Name                                                                 M/F     DOB                                         
Address                                                                         Town                                Zip               
School                                               Medical Insurance Y/N Carrier                                          

Parent/Guardian Information

Name                                                                     Name                                                            
Address                                                                 Address                                                         
Home Phone                                                          Home Phone                                                  
E-Mail Address                                                      E-Mail Address                                             
Employment Work Phone                                       Employment Work Phone                       
                                                                                                                                                    
Emergency Contact                                                                                                                      
Phone (Home)                                                       (Work)                                                           

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