Transcript Fitchburg Recreation Skate camp 2011 Registration Form

Fitchburg Recreation
Skate camp
2011 Registration Form
Ryan C. Joubert Skatepark
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Name:____________________________________
Address:__________________________________
City:_____________________________________
Phone:____________________________________
School:________________
Grade:__________
 Age:____________
 Date of Birth:_____/______/_____
 Have you ever skated before:________
 How many years:__________
 Week requested: __________
Please accept the above named person for participation in
the above named event. I am aware of the risks inherent
with this activity, and release the sponsors from
responsibility for any and all liability. I have determined
the nature of the planned activities and feel this participant
is of sufficient age, ability, and discretion to participate. I
also agree that participation is at the discretion of the City
of Fitchburg Recreation Department. Violation of the camp
rules and regulations could result in removal from the
current program for the remained of the session.
________________________
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Parent or Guardian Signature
Date
Emergency Medical Information:
Physician:__________________
Phone:__________
Insurance:_____________
Policy #:________
For office use only:
Date:___________ Registration #:___________