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PARTICIPANT NAME GENDER DOB
M/D/Y
ENTERING
GRADE
PROGRAM NAME SESSION LETTER
(A/B/C)
(if applicable)
CLASS
FEE
Total Amount Due: $
Participant’s Last Name: ________________________________________ First Name: ____________________________________
Parent’s Last Name (if participant under 18):__________________________ First Name: ________________ DOB(required): ______________
Mailing Address: _________________________________________ City/State/Zip: ______________________________________
E-Mail: _____________________________________ Home Phone: ____________________ Work Phone: ____________________
Cell Phone: _____________________________ Cell Provider (for text updates - optional):_________________________________
Emergency Contact (other than parent):___________________ Relationship: _________________ Telephone: ________________
Please list any special needs which will require accommodation for participation: ______________________________________
Please list any allergies (food, insect, plant, or medications): _________________________________________________________
Registrations can be made as soon as you receive this brochure.
Participants may continue to register for programs until they are
full. We do our best to accommodate those with special needs.
With few exceptions, our parks and facilities comply with the
Americans with Disabilities Act. Children and adults with spe-
cial needs are encouraged to participate in our programs. Staff
members are receptive to your needs and will do everything
possible to assist you. If you are interested in participating in
a program, but are not sure about the accessibility of a facility
or wish to discuss program details, please call the Recreation
Department and ask us about specics. Classes that do not have
the minimum number of registrations may be cancelled. Reg-
istrants will be notied by mail or phone and will receive a full
refund. Refunds will not be given once a class begins, and are
available up to 10 business days prior to the start of the pro-
gram. A $6.00 administrative fee will be charged when a refund
is requested. By participating in the Town of Colchester Recre-
ation programs, participants may be photographed for future
publicity or recognition of events. By signing up for the pro-
grams you willingly signed a waiver that grants the Colchester
Recreation Department permission to use your photograph to
promote their programs. Pictures taken in specic programs
may be used for up to 10 years. Non residents may register for
any program offered, on a space available basis, beginning on
January 1, 2021.
PAYMENT METHOD (CHECK ONE):
[ ] Check (payable to Colchester Parks & Recreation) [ ] Cash [ ] Credit Card (Visa, Mastercard, American Express, Discover Accepted)
Credit Card #: ______________________________ Exp: ____________ Security Code: _________ Zip of Cardholder: __________
Town of Colchester Release and Indemnity Agreement
Whereas, the undersigned has requested the use of services, equipment, or facilities belong-
ing to or under the auspices of the Town of Colchester, Vermont, and to engage in activities
for the executive benet of the undersigned: and Whereas, the Town of Colchester does
not wish to be liable for any damages arising from personal injury or property damage
sustained thereby:
Now therefore, in consideration of the mutual promises and other good and valuable con-
sideration, the undersigned does hereby for themselves, their heirs, executor, employers,
successors or administrators, and personal representatives;
A. Assume full responsibility for any personal injury or any damage to his/her personal
property which may occur directly or indirectly in the course of participating in rec. activi-
ties B. Fully and forever release and discharge the Town of Colchester, its agents, ofcials,
and employees, from any and all claims, demands, damages, rights or action, or causes
of action, present or future, whether the same be known, an anticipated or unanticipated,
resulting from or arising out of the above described activity. C. Agree that it is the intent
of the undersigned that this release and indemnity agreement shall be in full force & effect
any time after the execution hereof.
Name of Participant: ___________________________________________________
Signature (of parent or guardian under 18):_______________________________________
Date of Signature:_______________________________________________________
One form can be used
for all family members
that live in the same
household.
2021 REGISTRATION FORM
click to sign
signature
click to edit
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click to sign
signature
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