FAMILY
AMILY MEMBER WINTER/SPRING 2012
INTER/SPRING 2012 Please attach to participant registration form.
Name (Last)__________________________________(First)________________________ Birth date_________ Sex: M__ F__ Name (Last)__________________________________(First)________________________ Birth date_________ Sex: M__ F__ Name (Last)__________________________________(First)________________________ Birth date_________ Sex: M__ F__ Name (Last)__________________________________(First)________________________ Birth date_________ Sex: M__ F__ Relationship to Participant: Sibling_____ Spouse_____ Parent_____ Friend_____ Participant Name (Last)__________________________________ (First)_________________________________________
Parent/Guardian Information: If different from Participant Information, please complete: Name (Last)__________________________________________ (First)_____________________________________________ Address_________________________________________________ City__________________________ Zip_____________ Home Phone # (_______) ___________________________
Work Phone # (_______)______________________________
Please indicate any medical conditions, allergies, medication information, inappropriate activities etc. for the above listed individuals. __________________________________________________________________________________________________________ __________________________________________________________________________________________________________
Names of Family Member(s) Attending
Program # Program Name
EMBER REGISTRATION
EGISTRATION FORM ORM
Insurance NWSRA carries liability insurance only. The cost of medical insurance coverage for injuries would make program fees prohibitive, therefore it is the responsibility of each individual or family to provide their own medical insurance. NWSRA must have the following information, however, in case of an emergency.
Medical Insurance Company___________________________________________________ Policy # __________________________________________
NWSRA Waiver and Release of All Claims The NWSRA is committed to conducting its recreation programs and activities in a safe manner and holds the safety of participants in high regard. The NWSRA continu- ally strives to reduce such risks and insists that all participants follow safety rules and instructions that are designed to protect the participants’ safety. However, participants and parents/guardians of minors registering for the programs/activities listed above must recognize that there is an inherent risk of injury when choosing to participate in recreational programs/activities. You are solely responsible for determining if you or your minor child/ward are physically fi t and/or skilled for the activities contemplated by this agreement. It is always advisable, especially if the participant is pregnant, disabled in any way or recently suffered an illness, injury or impairment, to consult a physician before undertaking any physical activity. Recreational programs/activities are intended to challenge and engage the physical, mental and emotional resources of each participant. Despite careful and proper preparation, instruction, medical advice, conditioning and equipment, there is still a risk of serious injury when participating in any recreational program/activity. Understandably, not all hazards and dangers can be foreseen. Depending on the particular activity, participants must understand that certain risks, dangers and injuries due to inclement weather, slipping, falling, poor skill level or conditioning, carelessness, horseplay, unsportsmanlike conduct, premises defects, inadequate or defective equipment, inadequate supervision, instruction or offi ciating, and all other circumstances inherent to indoor and outdoor recreational activities/programs exist. In this regard, it must be recognized that it is impossible for the NWSRA to guarantee absolute safety. Please read this form carefully and be aware that in signing up and participating in the above identifi ed programs/activities, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your child/ward might sustain as a result of participating in any and all activities connected with and associated with said programs/activities (including transportation services/vehicle operation, when provided.).
I recognize and acknowledge that there are certain risks of physical injury to participants in these programs/activities, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of participating in these programs/activities against the NWSRA including its of- fi cials, agents, volunteers and employees (hereinafter collectively referred as NWSRA). I do hereby fully release and forever discharge the NWSRA from any and all claims for injuries, damages, or loss that my minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way associated with these programs/activities. I have read and fully understand the above important information, warning of risk, assumption of risk and waiver and release of all claims. If registering on-line or via fax, your on-line or facsimile signature shall substitute for and have the same legal effect as an original form signature.
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Parent/Guardian Signature__________________________________________________________________________________ Date_______________________________ Please Print Name________________________________________________________________________________________
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