Program Registration Form - The Municipality of the District of St. Mary's

Program Name:

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Program Start Date:

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You must fill out one form per child.

Please do not add multiple children in one form. All information is needed for each child attending the program.

Please note: If your child is staying after school for a recreation program, you must write a note in your child’s agenda for every week your child will be staying for the program. Teachers/staff must know when your child is NOT getting on the bus.

Participant Information:

Child’s Name(*)

Please type your full name.

Current Grade(*)

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Phone Number(*)

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Date of Birth(*)

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Age(*)

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Parent's Email(*)

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Full Mailing Address(*)

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Parent/Guardian Information:

Name(*)

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Work Phone(*)

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Cell Phone(*)

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Name

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Work Phone

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Cell Phone

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Emergency Contact Information (Other than parent/Guardian):

Name/Relation

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Work Phone

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Cell Phone

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Name/Relation

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Work Phone

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Cell Phone

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Additional Information:

Medical Conditions: List any medical conditions of allergies that recreation staff should be aware of. If your child has no medical conditions, please write None.

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Photos: Please sign if you DO NOT want your child’s photo taken.

Sign Above

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Child Pick-up: Please list all parties that have permission to pick-up your child from this program:

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WAIVER (Please Read):

I, the above named candidate (Age 19+) or one of the parents/guardians of the above named candidate (age 18 or under) for the above specified program(s) hereby give my approval myself or for that child to participate in any and all activities pertaining to the above program. IT IS UNDERSTOOD AND AGREED THAT THERE IS AN INHERENT RISK IN ANY PROGRAM AND THE MUNICIPALITY OF THE DISTRICT OF ST. MARY’S, ITS STAFF AND ITS PROFESSIONAL AND NON-PROFESSIONAL VOLUNTEERS ARE IN NO WAY RESPONSIBLE FOR DAMAGE TO OR LOSS OF PROPERTY, OR INJURY TO PARTICIPANTS. I, THE UNDERSIGNED, THEREFORE, RELEASE AND AGREE TO INDEMNIFY AND HOLD HARMLESS THE MUNICIPALITY OF THE DISTRICT OF ST. MARY’S, ITS STAFF AND PROFESSIONAL AND NON-PROFESSIONAL VOLUNTEERS, AND SPONSORS FROM ALL CLAIMS ARISING FROM ANY LOSS OR INJURY SUFFERED BY THE ABOVE NAMED PARTICIPANT ARISING FROM AND OUT OF ANY INJURY SUFFERED BY THE PARTICIPANT WHILE INVOLVED IN ANY RECREATIONAL PROGRAM.

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I have read and understand the above waiver

Please confirm that you have read and understand the above waiver.

Signature of Parent/Guardian(*)

Sign Above

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Security check(*)

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Form Date:(*)

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Recreation Program Registration Form

You must fill out one form per child.

Participant Information:

Parent/Guardian Information:

Emergency Contact Information (Other than parent/Guardian):

Additional Information:

Residents