Program:
Name of Participant: ________________________: DOB ___/ ___/______
Home Address: ________________________________________________
________________________________________________
Home #: _______________________ Work/cell: _____________________
Emergency Contact: ____________________________________________
Emergency #: _________________________________________
Allergies: _____________________________________________________
E-Mail Address: ________________________________________________
Authorized names, phone numbers and DL# of person(s) for child pick up
1..________________________________________________________
2. ________________________________________________________
Insurance Information
____ All participants must register and have insurance before participating in programs at Hazel Parker Playground. I want to be insured by the policy offered through the Department of Recreation.
____ I have my own insurance coverage with ___________________________
____ I, the undersigned, do hereby agree that the risk of injury is a possibility. While particular rules, equipment, and personal discipline may reduce this, the risk of injury does exist.
I, the undersigned release the City of Charleston Department of Recreation, sponsoring agencies, sponsors and contracted instructors from any and all liabilities that may result from participation and involvement in programs at HPP, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law. I understand the risks involved in this program, my personal responsibilities for adhering to rules and regulations, and accept them as a participant.
___________________________ ______________________________ ___________
Signature Print Date
