to access the registration/consent and release form

Town of Marblehead Parks & Recreation Program General Registration Form
#1 Legal guardian (OR adult participant if age 18+):
Date:
Mailing Address
Street
Home Phone (
Town
)
Cell Phone (
Zip Code
_)
E-Mail
(for receipts and program information only)
#2 Legal guardian (OR emergency contact not listed above):
Home Phone (
_)
Cell Phone (
)
Address (if different from above)
Street
Town
Zip Code
*FOR SUMMER PROGRAM(S), PLEASE USE GRADE ENTERING IN AUTUMN
M/F
Participant(s) name:
Gender
D.O.B
*Grade
see above
Fee
amount
Program / activity name
(please include sessions or dates)
$
$
$
$
PLEASE make checks payable t o “TO WN OF MARB LE H EAD”
TOTAL:
/ CASH (Sorry, no credit cards )
Payment method (circle 1): CHECK #
YES / NO (circle 1): Does participant(s) have any medical concerns/allergies we should know about?
(If “YES”, please fill out the health form on the back page).
YES / NO (circle 1): Can we use images taken of the above participating in our programs for promotional purposes
such as “Facebook” or “Twitter”?
YES / NO (circle 1): Volunteer if a program you have listed above is seeking volunteers?
(If “YES” you will be contacted by the Recreation Supervisor)
YES / NO (circle 1): Can we add your email to our monthly newsletter?
(If “YES” you will receive monthly updates from our department)
MARBLEHEAD RECREATION & PARKS CONSENT & RELEASE FORM
I,
, the undersigned 0 PARENT OR 0 LEGAL GUARDIAN of the above-named participant(s) OR 0 PARTICIPANT do hereby consent to
participation in the above listed athletic and/or recreational program(s) of the Town of Marblehead.
I agree and covenant to forever RELEASE, acquit, discharge and hold harmless the Town of Marblehead, its Recreation and Parks Department and any and all Town
employees, agents, board members, volunteers and any and all individuals and organizations assisting or participating in the voluntary athletic or recreational
programs of the Town of Marblehead (hereinafter, collectively, the “Town of Marblehead”) from any and all claims of any nature or kind whatsoever, actions, rights of
action and causes of action, damages, costs, expenses and fees, except those resulting from the Town’s gross negligence or in tentional, reckless or willful
misconduct, that may have arisen in the past or which may arise in the future, directly or indirectly, from any and all known or unknown personal injuries to the
participant or property damage, which the participant has suffered or may hereafter suffer, resulting from or in any way growing out of, directly or indirectly,
participation in the Town of Marblehead voluntary athletic and/or recreational programs and/or activities.
I hereby forever RELEASE, indemnify, defend and hold harmless the Town of Marblehead against any and all legal claims of any nature or kind whatsoever and
proceedings of any description, with the exceptions referenced above, that may have been asserted in the past or may be asserted in the future, directly or indirectly,
arising from personal injuries to the participant or property damage resulting from or in any way growing out of, directly or indirectly, participation in the Town of
Marblehead voluntary athletic and/or recreational programs and/or activities.
I further hereby affirm that I have read this Consent and Release Form and that I understand the contents of this Form. I understand that participation in these
programs is voluntary and that the participant is free to choose not to participate in said programs. By signing this Form, I affirm that I have decided the participant
may participate in the Town of Marblehead’s athletic and/or recreational programs and/or activities with full knowledge that the Town of Marblehead will not be liable
to anyone for any personal injuries to the participant or property damage suffered while in the voluntary participation of the Town of Marblehead athletic and/or
recreational programs and/or activities.
Printed Name
Signature
Date
*THIS IS TO BE FILLED OUT ONLY IF PARTICIPANT HAS A HISTORY OF HEALTH PROBLEMS*
PARTICIPANT’S NAME:
1) Has participant been in good health in the past year?
If no, please explain:
2) Has participant had any of the following in the past three years?
a.) seizures
b.) severe injuries or accidents
c.) fractures or broken bones
d.) hospitalizations
e.) operations
f.) history of a heart murmur
g.) medicines or treatments prescribed by a physician or clinic
h.) history of chickenpox
If yes to any of the above please explain:
DOB:
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
3) Is participant currently taking any medications?
If yes, please list your child’s medications:
Yes
No
4) Is participant currently receiving any type of treatment?
If yes, please explain:
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
5) In the past year, has participant had any of the following problems?
a.) problems with eyes or seeing
b.) excessive bleeding when cut
c.) problems with ears or hearing
d.) allergies
e.) physical restrictions due to any heart problem
f.) asthma or breathing problems
g.) sleeping difficulties
h.) behavior problems
i.) difficulties with physical activities
j.) problems with general development and maturity
k.) change in family structure
If yes to any of the above, please explain:
6) Does participant wear glasses, contact lenses or a hearing aid?
Please circle those which apply.
7) Has participant seen a dentist in the past year?
Dentist name and phone number:
Yes
Yes
No
8) Has any family member developed any serious health problems within the last year? Yes
If yes, please explain:
9) Do you think participant is fit to participate in all program activities?
If no, please explain:
Parent/ Legal guardian signature
Yes
No
No
No
Daytime phone number