Roseland Recreation Department 19 Harrison Avenue
(973/403-6822)
25th Annual Father / Child Bowling Night – “FATHER’S DAY EVENT”
Mayor John Duthie
WHO: Roseland Boys and Girls (Grades K through 6)
WHERE: Eagle Rock Lanes
424 Eagle Rock Avenue, West Orange, NJ 07052
DATE: Friday Night, June 17, 2016
TIME: 7:00 p.m. - 9:00 p.m. (Check - In Time 6:30 p.m.)
FEE: $20.00 per person (Includes 2 Games and Rentals of Bowling Shoes)
(Make Checks Payable To: BOROUGH OF ROSELAND)
DEADLINE: Limited to First 100 People or June 15th
Refreshments will be provided (Pizza and a Soft Drink)
Awards will be given to champions and runner –ups. A medallion will be given to all youth participants. (Categories: K – 2nd Grades, 3rd – 4th Grades and 5th – 6th Grades)
DIRECTIONS: Eagle Rock Avenue (East). Cross over Pleasant Valley Way and Prospect Avenue. After crossing Prospect Avenue, turn right into drive, lanes are in the rear.
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2016 FATHER/CHILD BOWLING NIGHT Detach Here Do Not Write Below:
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Mail to: Roseland Recreation Department Cash Check Amount Date Rec’d
140 Eagle Rock Avenue, Roseland, NJ 07068
Child’s Name______Age____ Grade____
Child’s Name______Age____ Grade____
Child’s Name______Age____ Grade____ Name______Address______
Home Phone______Emergency Phone______Email______
Do you have any health conditions the Recreation Department Staff should know about? No___Yes___ Explain:______
THE RECREATION DEPARTMENT RECOMMENDS THE DISCLOSURE OF RELEVANT HEALTH INFORMATION, UNLESS THE ROSELAND RECREATION DEPARTMENT IS NOTIFIED IN WRITING, THE STAFF WILL BE FORWARDED ALL INFORMATION ON THE REGISTRATION FORM, INCLUDING HEALTH CONDITIONS.
Child Photo / Video / Release Form
I grant permission for the Borough of Roseland, Roseland, New Jersey to use photograph(s)/moving image(s) of my child participating in Borough programs and/or activities for promotional purposes. I understand that photographs or recordings may be utilized by the Borough at its discretion for materials including, but not limited to: newsletters, brochures, television, video tape and flyers. Photographs sent to the local newspaper may have names noted. There will be no valuable consideration paid as a result of this activity. Yes ___ No ___
PARTICIPANT WAIVER OF CLAIM FORM: As partial consideration for the Borough of Roseland providing______(“Participant”) with the opportunity to participate in the Father/Child Bowling Night Event I, ______, as parent or guardian of Participant, on his or her behalf and on my own behalf and that of my spouse or partner, agree to hereby 1) acknowledge that there are foreseeable and unknown risks inherent in participation in the Program, 2) release, indemnify and hold harmless the Borough of Roseland, it officials, departments, employees, volunteers, contractors, insurers, including the NJIIF from and against all claims, losses, costs an damages arising from Participant participation in the Program, and 3) agree that for any loss or damage suffered by Participant will be turned over to parent / guardian’s insurance company. I also represent that the Participant has been cleared by his/her physician to participate in the Program. If a medical emergency should arise and the parent / guardian cannot be reached immediately at home phone number (______), at work phone number (______), at the emergency phone number (______) or via cell phone number (______), I, parent or guardian, hereby grant medical personnel to take whatever means he or she deems necessary to safeguard the welfare of the Participant.
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Signature Date
PARENTAL ASSISTANCE: Score Keeper____
NAME______Home Phone______Cell Phone______
FOR MORE PROGRAM INFORMATION, TURN TO COMCAST CHANNEL 35 OR VERIZON CHANNEL 46, CHECK OUT OUR WEBSITE AT WWW.ROSELANDNJ.ORG OR LOOK IN THE PROGRESS NEWSPAPER