Milton Recreation Department
PROGRAM REGISTRATION FORM
miltonvt.gov/recreation I 802-893-4922 I recreation@miltonvt.gov
43 Bombardier Road Milton, VT 05468
HEAD OF HOUSEHOLD INFORMATION:
Name: __________________________________________Address: _________________________________________
* Town: _________________________________________State: _________________ Zip: _____________________
* Non-Milton Resident: add $5.00 per program
Cell: ___________________________ Work: ______________________ Other phone: __________________________
Email: ____________________________________________________________________________________________
□ Check here if you would like to receive the Milton Recreation e-Newsletter with upcoming program and event information!
Emergency Contact: _________________________________________ Phone: ________________________________
Please describe below any physical conditions, medication, dietary restrictions, allergies or other information which is
necessary to be aware of to ensure participants’ health and safety. (i.e.: ADHD, bee stings, nut allergy, etc...)
□ None □ _______________________________________________________________________________________
♦ How did you hear about the program(s) below? ________________________________________________________
♦ Please consider making a contribution to the Milton Recreation Department Scholarship Fund: $____________ ♦
You can assume you are in the class once you submit this registration form and payment. If the class is full, you will
be notified and placed on a waiting list. If the class is cancelled or postponed, you will be notified.
RELEASE CONSENT:
I have read and understand the information regarding the program for which I am registered. I have noted any physical or medical conditions
I have which may affect my participation and I meet the standard required for participation. I assume the entire risks incidental to the nature
of this activity, including risks which are not specifically foreseeable. I will follow the rules and regulations provided by the activity leader. I, the
undersigned, hereby release and agree to indemnify and hold harmless the Town of Milton, the Recreation Commission, Contracted Businesses,
Staff, Volunteers and all affiliates from all liability resulting from the property damage, personal injury and/or other loss suffered by me/my child
while participating in the above program(s). I grant permission to have a physician attend the above named participant, if it is deemed necessary,
during participation in Milton Recreation programs. Photo Release: I hereby consent to and authorize the Town of Milton Recreation Department
the right to publish, reproduce and use for advertising or any other purpose, any photograph, video image, an audio recording or other likeness of
my child or family member. I have read this document carefully and sign it voluntarily with full knowledge of its significance.
SIGNATURE: ____________________________________________________________ DATE: ___________________
(Participant or Parent/Legal Guardian if Participant is under age 18)
REFUND POLICY: I have read and understand the Refund Policy stated below: _________ (please initial)
Unless otherwise stated, refunds will be available only until one week prior to the first day of a program or activity. A $10.00 administrative
fee will be charged for processing the refund. If a program is cancelled by the Milton Recreation Department, a full refund will be issued and
no administrative fee will be charged. Please note that it may take a few weeks for a refund to be processed.
PLEASE complete this form and submit to the Town of Milton Recreation Department with a check made payable to the
Town of Milton or cash. Or register and pay for Recreation programs with a credit or debit card using Milton
Recreation’s online registration at miltonvt.gov/recreation. Registration and payment for all programs is requested one
week in advance of program start date.
QUESTIONS? Call the Milton Recreation Office at 802-893-4922, email recreation@miltonvt.gov or visit
miltonvt.gov/recreation.
05/09/18 kmd
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