Newport Recreation Department Registration Form

Newport Recreation Department Registration Form

Program/Activity_________________________ Date____________
Name____________________________________________________
Address___________________________________________________
Email address______________________________ (example: nrd@nhvt.net )
Date of birth__________________________ Age___________________
Male___ Female___ School_______________________ Grade________
Insurance____________________________ Policy #_______________
Father's Name_____________________________________________
Cell#________________ Home#______________ Work#_____________
Mother's Name_____________________________________________
Cell#________________ Home#______________ Work#_____________
Emergency Contact Name___________________________________
Cell#________________ Home#______________ Work#_____________

*************** Medical Release Form **************
I give my permission for my child, __________________ to participate in the Newport Recreation Department program and hereby authorize the Newport Recreation staff, to arrange medical or surgical care for my child in an emergency which may occur during a N.R.D. sponsored program if I am unable to be reached by telephone, etc.
RESPONSIBILITY: Neither the Newport Recreation Department, any master, any coach, nor can anyone else assume responsibility for possible accidents. The Newport Recreation Department does NOT carry accidental or medical insurance for the participants in any of their recreation programs.
ATTENTION!! By signing this form I also give permission for my child to be filmed/photographed for possible broadcast on NCTV or other programs. If you are opposed to this please note on this form. Thank you!
Parent/Guardian Signature___________________________________
Print Names: Father_____________	Mother_____________