Primary Guardian: ________________________________________________ Date of Birth: ____________________________
Address ______________________________________________ Town: __________________ Zip _______________________
Home Phone (______)_____________ Work Phone (______)____________ Emergency Phone (_____)______________
E-Mail _______________________________________________________
Name of Emergency Contact: ________________________________ Relationship: _______________________________
Child’s Name ___________________________________ Sex ______ Grade _______ Birthday ______________________
1. Class Title ____________________________ Activity # __________ Sec. ____ Day & Time ________ Cost______________
Child’s Name ___________________________________ Sex ______ Grade _______ Birthday ___________________________
1. Class Title ___________________________ Activity # __________ Sec. ____ Day & Time ________ Cost______________
For Phi Slamma Jamma, Shooting Stars and Sky League Basketball Circle T-shirt Size: Adult S, M, L, XL, XXL
Total Enclosed ______________
Make checks payable to: “Town of East Hartford”. Please make sure that you fill out this form completely to assure proper registration. The grade is only required for youth programs. Grade listed that child is in beginning in September of the current year.
The Town of East Hartford Park & Recreation Department Program (as defined below, “Program”) involves a variety of physical activities and there is an element of risk involved, which each participant must assume (including injury, disability or death). I affirm that my health is adequate and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness to participate in the Program. The undersigned hereby agrees:
1. I fully assume all risks associated with utilization of and participation in the program(s) listed above and agree not to sue and hereby release the Town of East Hartford, its agents, servants, employees, volunteers, elected officials boards and commissions (collectively “The Town”), from all liability should an injury to me or listed participant occur during participation in the said program(s).
2. I, for myself and for my heirs, executors, administrators, and legal representatives, agree to defend, indemnify and hold harmless the Town, from any and all claims, suits or demands by anyone arising from my use of OR participation in THE PROGRAM.
3. If I am a parent or guardian signing on behalf of a child or ward, I make these representations and agreements on behalf of My child or ward.
4. I give permission to the Parks & Recreation Department to use any photo or video taken during participation for promotional materials.
Signature ___________________________________________________ Date ______________________
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