program registration form

Program Registration Form

Please submit completed forms to: Jackson Township Parks & Recreation Department 5735 Wales Avenue NW, Massillon, OH 44646 Fax (330) 832-5936
Participant Information

Name_______________________________________	Age______ Birth Date ___________

Address ____________________________________	City/State/Zip ______________________________

Phone____________________________	Emergency Phone__________________________

Parent/Guardian E-mail ____________________________	Township Resident Non-Resident

Please list any known allergies, medications, special needs or accommodations relating to this participant:
___________________________________________________________________________________________________
Program Information

Program Title(s)	Date(s)	Time(s)	Fee(s) (if applicable)



		Total	$____________
		Make checks payable to: Jackson Township Parks

In the event of an emergency and reasonable attempt to contact me has been unsuccessful:

I hereby give my consent for: 1) The administration of any treatment deemed necessary by a licensed physician or dentist; and 2) The transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concur necessary for such surgery, are obtained prior to the performance of such surgery.

I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the program authorities to take no action.

Participant Waiver/Release Of All Claims

I, the participant, the parent, or legal guardian of the participant, a voluntary participant in this program sponsored by the Jackson Township Parks & Recreation Department, am aware that there are certain risks of injury involved in any sport or recreation activity. Bearing this in mind, and with full knowledge of the physical capabilities or limitations of myself/child, I hereby agree to assume for myself/child such risk of injury. I, the undersigned further agree with the intension of binding myself, my spouse, my heirs, my legal representatives and my assigns, voluntarily, knowingly and expressly release the Board of Trustees of Jackson Township, Stark County, Ohio or any member or employee thereof from all claims, demands, actions, judgments and executions that I now have or may or that anyone claiming through me may have or claim to have against Jackson Township, Ohio or any member or employee thereof, created by or arising out of my participation in any of the programs offered in the Jackson Township Parks. By signing this form, I fully understand that I am releasing the above named parties from any liability arising our of my participation in any of the above programs offered in any of the Jackson Township Parks described above and specifically the program(s) described above. Finally, I understand that by registering for any Jackson Township Parks & Recreation program, I agree to allow publication of any photos taken at any program or event sponsored by the Jackson Township Parks & Recreation Department.

__________________________________________________

Signature (Parent or Guardian if under age 18)

___________________

Date

In the event of an emergency and reasonable attempt to contact me has been unsuccessful:
I hereby give my consent for: 1) The administration of any treatment deemed necessary by a licensed physician or dentist; and 2) The transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concur necessary for such surgery, are obtained prior to the performance of such surgery.
I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the program authorities to take no action.
Participant Waiver/Release Of All Claims
I, the participant, the parent, or legal guardian of the participant, a voluntary participant in this program sponsored by the Jackson Township Parks & Recreation Department, am aware that there are certain risks of injury involved in any sport or recreation activity. Bearing this in mind, and with full knowledge of the physical capabilities or limitations of myself/child, I hereby agree to assume for myself/child such risk of injury. I, the undersigned further agree with the intension of binding myself, my spouse, my heirs, my legal representatives and my assigns, voluntarily, knowingly and expressly release the Board of Trustees of Jackson Township, Stark County, Ohio or any member or employee thereof from all claims, demands, actions, judgments and executions that I now have or may or that anyone claiming through me may have or claim to have against Jackson Township, Ohio or any member or employee thereof, created by or arising out of my participation in any of the programs offered in the Jackson Township Parks. By signing this form, I fully understand that I am releasing the above named parties from any liability arising our of my participation in any of the above programs offered in any of the Jackson Township Parks described above and specifically the program(s) described above. Finally, I understand that by registering for any Jackson Township Parks & Recreation program, I agree to allow publication of any photos taken at any program or event sponsored by the Jackson Township Parks & Recreation Department.

__________________________________________________ Signature (Parent or Guardian if under age 18)	___________________ Date