FREEDOM AREA RECREATION COUNCIL

REGISTRATION FORM  

DATE __________________

NAME: _______________________________________________DATE OF BIRTH: _____________

ADDRESS: _____________________________________CITY ________________ZIP__________

PHONE: _____________ E-MAIL ________________ENTERING GRADE ____  AT _____________

IN EMERGENCY CALL _____________________________________ PHONE _________________

HEALTH CONCERNS? ___YES ___NO       IF YES, EXPLAIN ON BACK.

_____________________________has permission to participate in the activity named below.  I understand that he/she is subject to the school and council rules of conduct.  The undersigned acknowledges that the Freedom Area Recreation Council does not provide any registrant medical or hospitalization insurance whatsoever, and hereby waives any and all claims against the Freedom Area Recreation Council and the Carroll County Department of Recreation & Parks or any other person affiliated with the Freedom Area Recreation Council program for injuries sustained while watching or playing games or traveling to and from games or participation in any leisure time activity. I also agree that photographs taken of my child or me while participating in this activity may be used for publicity purposes.

ACTIVITY ___________________ SIGNATURE ______________________________

RETURN CHECKS WILL BE CHARGE A $25.00 FEE                                     PARENT/ GUARDIAN OR PARTICIPANT OVER 18

PERSON AUTHORIZED TO PICK UP CHILD IF PARENT/GUARDIAN IS UNABLE

_____________________________________________ PHONE ________________

SESSION _____________________FEE _____________CHECK _______CASH _______ DATE _________