NO REFUNDS. A FEE MAY BE ASSESSED FOR ANY RETURNED CHECKS.
Program ______________________________________ Program Fee:_____________________________________
Parent or Legal Guardian Information
*Indicates required fields *(Please clearly print all fields.)
*Last Name *First Name
*Birthdate (mm/dd/yy) *Gender: Female Male
*Address
*Zip Code City State
Email address:
Primary Emergency Contact Information
First Name Last Name
Relationship Phone ( ) -
Child /Participant Information
1 *Last Name *First Name
*Birthdate (mm/dd/yy) *Age ____ *Gender: Female Male
If this is a child, what grade are they in?
Are there any allergies or medical needs?
2 *Last Name *First Name
*Birthdate (mm/dd/yy) *Age ____ *Gender: Female Male
If this is a child, what grade are they in?
Are there any allergies or medical needs? ________
What is the best number to reach you?
*Primary Phone (______) ______-_______
Secondary Phone (______) ______-_______
Other Phone (______) ______-_______
Can your child be released to anyone other than parent or
legal guardian? Yes__ No __ If yes, please list below.
_________________________________________________
_________________________________________________
_________________________________________________
NO REFUNDS. A FEE MAY BE ASSESSED FOR ANY RETURNED CHECKS.
3 *Last Name *First Name
*Birthdate (mm/dd/yy) *Age ____ *Gender: Female Male
If this is a child, what grade are they in?
Are there any allergies or medical needs?
4 *Last Name *First Name
*Birthdate (mm/dd/yy) *Age ____ *Gender: Female Male
If this is a child, what grade are they in?
Are there any allergies or medical needs?
Please read carefully and sign below
Waiver and Release
I hereby agree to permit my child to participate in the above program(s) sponsored by the Recreation Department of the Town of Narragansett, its officers,
directors, employers, and agents (herein collectively called “the Town”) upon the understanding and condition that:
My child(ren) is presently being treated for a medical condition: Yes No
If yes, please explain: See above referenced explanation
I acknowledge that the Town has advised me of the medical risks that may result in such participation and I represent to the Town that I have consulted my
child’s personal physician and that my child is physically capable of such participation without injury.
I hereby waive and release the Town from any and all claims, liabilities, and expenses arising from my participation in the said program with the exception of
claims resulting from gross negligence or willful misconduct on the part of the Town.
I also hereby agree to permit my child to be photographed and/or videotaped while participating in the above program sponsored by the Recreation
Department of the Town of Narragansett. By signing this form, I am permitting photographs and/or videos of my child to be used by the Town for purposes
of advertising, newspaper articles, department displays, etc.
I hereby execute and deliver this Waiver and Release to induce the Town to permit my child to participate in the program.
Signature: ___________________________________________ Date: ___________________________________________
Printed Name: _____________________________________________________________________________________________
For Office Use Only
Cash/Check #: __________ Amount: ____________ Date: ___________ Clerk: _________ Birth Certificate Received: Yes/No
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