Head of Household First Name (required) Head of Household Last Name (required)
Address (required) City (required) Zip Code
Primary Phone (required) Daytime Phone Email Address (requested for receipt and program updates)
Emergency Phone #1 (Person not registered for event, required) Emergency Phone #2 (Person not registered for event, required)
First Name Last Name Gender Birth Date Grade
Activity Name Activity Number Activity Date Time Fee
Please make checks or money orders (DO NOT MAIL CASH) payable to: CTPR Total
Allergies the Recreation Department should be aware of: (Name /Allergy)
Check here if you need accommodation in order to fully participate in any activity.
You will be contacted to discuss your specific needs.
(REQUIRED for all participants under age 15 attending a class that meets more than one day)
Please indicate how you would desire your child to exit CTPR
Allowed to come & go on his/her own Release to parent, guardian or designated adult only
List adult names:
WAIVER OF LIABILITY, WARRANTY OF PHYSICAL HEALTH, PHOTO RELEASE & PARENTAL CONSENT
We acknowledge that participation in recreational activities carries the risk of serious injury or death from occurrences during activities, including, but not limited to; being struck by objects, slip, trip or fall, being injured by other participants, and other health hazards. We fully release and absolve from liability the Charter
Township of Clinton, its employees, agents contractors and those in concert and participation with it from any and all liability, injury or damages on behalf of our child, and individually on behalf of ourselves. This release extends to personal and bodily injury, as well as property damage. The above includes a waiver of
liability and should be read carefully and fully before signing. I the undersigner, hereby agree to allow the individual(s) named heron to participate in the Charter Township of Clinton Parks and Recreation activities. I certify that, to the best of my knowledge, the participant(s) named hereon is/are physically fit and able to
engage in Parks and Recreation activities. In case of emergency, I give my permission for emergency medical treatment. This form shall be considered valid until canceled or changed in writing by the undersigned parent/guardian/participant. We, being either the natural or adoptive parents or legal guardian for the
individuals whose names are set forth on the registration form, represent and warrant that the child is physically healthy and able to participate in the activities for which the child is registered, acknowledging the full understanding of such activities and an opportunity to review with the Department any and all questions
regarding such activities. We further represent that we have full authority on behalf of such child or children to consent to the child’s participation and do consent to such participation. I hereby authorize the Charter Township of Clinton Parks & Recreation Department to use all photos, both video and audio portion of video
tapes on which I or my dependent appears. I understand that portions of these tapes may be used in other programs, training aids, and production at the discretion of the Township of Clinton Parks and Recreation.
Date ___ _
Opt out – I do not authorize the use of any photos, video, or audio in which I or my dependents appear.
Credit Card Information
Signature – REQUIRED for payment authorization. We cannot accept digital signatures at this time
Visa M/C Exp. Date __________ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ CVS
Mo / Year Credit Card Number (3 digit code on back)
Call C.T.P.R. at (586) 286-9336, or email us at Recreation@clintontownship.com if you have any questions.
Send the form to C.T.P.R., 40700 Romeo Plank Rd.,Clinton Twp., 48038 or fax to (586) 723-8282; Make checks payable to: C.T.P.R.
One Family per Household Allowed on Each Registration Form
ALL information is required for registration to be processed