_____________________________________________

Child’s Name

 

_____________________________________________

School Attending   Age/Grade

 

_________________________________  M / F

Email       Sex (circle one)

 

_____________________________________________

Street Address

 

_______________________(___)_______________

Town, State, zip                   home telephone

 

______________________(__ _)____________________

Parent/Guardian’s Name      Cell #

 

______________________(____)____________________

Parent/Guardian’s Name   Cell #

 

______________________(____)____________________

Doctor’s Name    telephone

 

_______________________________________________

Insurance Provider  Policy #

 

_______________________________________________

Subscriber’s Name    Relationship

 

_______________________________________________

Program/Event Attending

 

Photo Policy: By participating in a program, you give permission to take and publish photos of you participating, along with photo identification.  If you do not wish to be photographed, you must include this request, in writing, along with your permission form.

 

Medical & Behavioral Information: Please state any medical conditions or allergies of which the staff should be aware. Please note any special recommendations/goals which would be helpful to the staff to understand.

 

______________________________________

 

In the case of an emergency, who shall we contact if a parent/guardian cannot be reached?  We must have TWO people to call upon.

 

_____________________(____)_____________

Name   telephone

 

____________________(_____)______________

Name   telephone

Consent, Release and Indemnity Agreement:

I/We, the undersigned do herby consent to my own and/or my child’s participation in voluntary programs of the Town of North Reading’s Youth Services Department.

 

I/we also agree to forever release the Town of North Reading, and all of their employees, agents, officials, board members, volunteers and any and all individuals and organizations assisting or participating in programs of the Youth Services Department (“the Releasees”) from any and all claims, actions, rights of action and causes of action, damages, costs, loss of services, expenses, compensation and attorney’s fees that may have arisen in the past, or may arise in the future, directly or indirectly, from known and unknown personal injuries to myself or my child or property damage resulting from my or my child’s participation in the Town of North Reading’s voluntary programs in the Youth Services Department which I/we may now or hereafter have as the participant or as the parent(s) or guardian(s) of a said minor child and which said minor child has or hereafter may acquire, either before or after reaching majority.

 

I/We also promise, to indemnify, reimburse, defend and hold harmless the Releasees against any and all legal claims and proceedings or any description that may have been asserted in the past, or may be asserted in the future, arising directly or indirectly, including damages, costs and attorney’s fees, arising from personal injuries to me or my child or property damage resulting from my own or my child’s participation in the Town of North Reading’s voluntary programs in the Youth Services Department.

 

I/We further affirm that I/we have read this Consent, Release from Liability and Indemnity Agreement and that I/we understand the contents of this Agreement.  I/We understand that my or my child’s participation in these programs is voluntary and that my child and I are free to choose not to participate in said programs.  By signing this agreement, I/we affirm that I/we have decided to allow myself and/or my child to participate in these programs with full knowledge that the Releasees will not be liable to anyone for personal injuries and property damage which myself or my  child may suffer in these programs.  I/We understand that North Reading Youth Services Department further

Reserves the right to charge the participant or the parent or guardian of a minor for costs incurred or charged for damages to supplies or property while participating in a program or event.

 

This release is good for the above listed participant for all programs run through Youth Services for the year 2010.

 

 

_______________________________________

Signed    Date

Permission and Emergency Information Sheet