SALEM RECREATION
REGISTRATION FORM
Name/Adult: ___________________________________________________________________________________
Mailing Address: _______________________________________ Town:___________________________________
Day Phone:
____________________________________ Evening Phone: __________________________________
E-mail Address:_________________________________________________________________________________
Emergency Contact:
____________________________________ Phone: __________________________________
ASSUMPTION OF LIABILITY
Participation in the activity may involve risk of injury. As a parent, guardian or participant, I am aware of these hazards and my ability to participate. I
hereby agree to release, discharge and hold harmless the Town of Salem, its employees, contracted instructors and volunteers from the liabilities which
may occur while participation in the activity. I understand that participation in any recreational or sport activity involves risk. I further understand that
the Town of Salem does not provide accident/medical insurance for program participants. In addition, I give permission for the child(ren) to be treated by
qualied medical personnel in the event that the above named parent/guardian can not be reached at the phone numbers provided. I also hereby give my
permission to the Town to use any photographs, motion pictures, recordings, or any other media record as said activities in which I and/or said child(ren)
appear for any lawful purpose.
Signature Date
Signature of Parent/Guardian, if participant is under18 Date
CANCELLATION POLICY: No refunds will be given within two weeks prior to start of program if you choose not to participate in the
program. A minimum of participants must be registered in order for program to be held. Payment will be refunded if program is cancelled.
PLEASE SEND FORM TO: Town of Salem Recreation, 270 Hartford Road, Salem, CT 06420
PLEASE MAKE CHECKS PAYABLE TO: Town of Salem
INFO/INQUIRIES: recreation@salemct.gov | 860.859.3873, x275 | www.salemct.gov
FOR OFFICE USE ONLY
DATE: _______________________ REC’D BY: ______________
CASH/CHECK#: ______________ AMOUNT: ______________
TOTAL DUE:
NON-RESIDENT FEE ($5.00 PER CLASS):
NO REGISTRATION WILL BE COMPLETED
WITHOUT PAYMENT
YOU MUST PRE-REGISTER FOR ALL PROGRAMS
GradeParticipant Name ActivitySex Session CostDate of Birth
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