Town of Clay Recreation and Human Resource – Youth Permission Waiver

I understand participation in (name of event) __________________________________ may involve rigorous physical activity and risks of physical injury, and we assume these risks. I hereby give consent for emergency transportation and treatment in the event of illness or injury. I hereby accept responsibility for the payment of any emergency transportation or treatment on behalf of the participant. I further certify the participant is in good physical condition, and has no medical or physical conditions that would restrict his/her participation in this event.

(Parent/Guardian signature)_____________________________________________________________________________on this (Date): ___________________, 2008 does hereby covenant and agree to release and hold harmless the Town of Clay from and against any and all liability, loss, damages, claims, or actions (including costs and attorney fees) for bodily injury and/or property damage, to the extent permissible by law arising out of participation in

(name of event) _________________________________________________________________________________________________during (dates)___________________________________________________________, 2008.

Pictures and other materials, which include my child, may be used for Town of Clay promotional purposes.

There is no medical insurance carried by the Town of Clay for program participants. There are no refunds once a program begins.

REFUNDS IN FULL MAY BE GIVEN ONLY 48 HOURS IN ADVANCE OF PROGRAM START.

Child’s Name: _________________________________________________________________________________________________________

Street Address: ____________________________________________City: _________________________ State:______ Zip: ______________

Date of Birth: ________________________ Age: ________Grade entering: _________ School: ______________________________________

Home Phone # ______________________Work Phone #: _______________________________Cell #: ________________________________
Email Address: (optional): ______________________________________________________________________________________________

Medical/Allergy History: _____________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Additional Person/Phone # to contact in an emergency: ____________________________________________________________________________________________________________________________________

Check/Money Order #: __________________________________ Cash Receipt # __________________________________ Amount Paid:______________________

PLEASE COMPLETE BELOW IF REGISTERING FOR SUMMER PLAYGROUND PROGRAM, FIELD TRIPS OR OUR COMMUNITY SCHOOL PROGRAM.

NOTE: PARENT SHOULD PICK UP THEIR CHILDREN ON TIME! LATE PICK-UPS WILL RESULT IN YOUR CHILD’S DISMISSAL FROM OUR PROGRAM.

If you give permission for your child to walk home, please sign on the following line and list the time when your child is allowed to leave:

Parent/Guardian Signature: __________________________________________________________________ Time: _____________________

Please list below the person/persons and their phone number, other than yourself that are allowed to pick up your child from our program:

Name: __________________________________________________________________________________ Phone # _____________________

Name: __________________________________________________________________________________ Phone # _____________________

Name: __________________________________________________________________________________ Phone # _____________________

Name: __________________________________________________________________________________ Phone # _____________________

Parent/Guardian Signature: _________________________________________________________________ Date: _______________________