ADULT PROGRAM REGISTRATION AND RELEASE FORM
Program Name______Session Start Date/Time______
Fee:______Paid with (please circle one) CASH CHECK CREDIT CARD ONLINE
Participant’s Name______AGE/DOB______M/F______
Mailing Address ______Town______Zip______
E-Mail______Phone ______Cell Phone______
Emergency name and phone number______
Existing Medical Conditions, Allergies and/or Current Daily Medications? ______
______
______
In compliance with the National HIPPA Law, this information will be kept confidential and will be used in emergency situations only. The Windham Parks & Recreation Department will update this information with you on an annual basis.
I ______am participating in the Windham Parks and Recreation Department Program/Trips and agree to all responsibilities in case of an emergency.
As the undersigned I agree, understand and hereby assume all risks in connection with my participation in the Windham Parks and Recreation Department activities and hereby release, indemnify, forever the Windham Parks and Recreation Department along with their representatives, agents, affiliates, officers, directors, servants, employees, successors, and assigns from all liability for any injuries, damages, claims or actions in law or in equity and from all claims by me, my estate, my family, heirs, and assigns arising in any way, directly or indirectly, from my participation in the Windham Parks and Recreation Department programs.
I the undersigned authorize the Windham Parks and Recreation Department., its agents, or any independent contractors working on its behalf to call for any medical care that they deem appropriate or necessary in my behalf during the course of the program. I further authorize any medical personnel to administer any required emergency medical treatment in the event that a guardian/family member cannot be reached by the telephone numbers provided on this form. The Windham Parks and Recreation Department reserves the right to refuse services to any participant if the administration deems it necessary for the safety of the participant, other program participants, or staff.
I have carefully read the following release language and completely understand its content. I sign this document for myself as an individual.
Participant Signature______Date______