Kensington Recreation Committee
Program Title:_______________________Dates & Times of Program:_____________
FOR CHILDREN:
As the legal guardian for____________________ I realize and accept the fact that this facility has risks and dangers to the player who will be participating in Kensington Recreation programs.
Child’s Name_____________________________ Age_____ Date of birth_______________ Grade_____
Street Address ___________________________Town ____________Zip______
Home Phone _______________ Cell Phone or Beeper # ___________________e-mail_______________________
Parent or Guardian Names_______________________________________________
In case of emergency: Phone # & name (1) ________________________ (2) ______________________
FOR ADULTS:
Name________________________________ Age_________ Date of birth_____________
Street Address ___________________________Town ____________Zip______
Home Phone _______________ Cell Phone or Beeper # _____________________e-mail__________________
In case of emergency: Phone # & name (1) ________________________(2)______________________
**The Kensington Elementary school gymnasium is a multi-purpose facility. **I realize and accept the fact that this facility has risks and dangers to the player who will be participating in Kensington Recreation programs.
I, agree that I hereby release, discharge and/or otherwise indemnify the Kensington Recreation Committee, its affiliated organizations and sponsors, and their employees and associated personnel, including the owners of fields and facilities utilized for Recreation Committee activities against any claim by me as a result of participation in Kensington Recreation programs and activities and/or being transported to or from the same, which transportation I hereby authorize.
I hereby give permission for the adult supervisor to give simple first aid if necessary, or in the event of a more serious accident, to be transported to a hospital to receive emergency medical treatment. I also authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary and I authorize the hospital to undertake examination and emergency treatment if warranted.
List any special medications, allergies or other conditions that the Kensington Rec. should be aware of: ____________________________
Doctor__________________________ Phone #_________________
Name__________________________________
Signature____________________________________ Date_____________________
If you have any questions, comments, or concerns please bring them to the attention of the program coordinator.