Holderness Recreation Department
Program Registration Sheet
Participant Names M/F DOB Grade Program Cost
Total
_____
Parent Guardian Names: _____________________________________________________
Physical Address: ___________________________________________________________
Mailing Address:____________________________________________________________
Home Phone: ____________________________Work Phone:____________ Cell Phone: ___________
E-mail Address_____________________
Emergency Contact ( other than yourself): ___________________________Phone:_________________
Allergies/Medications/Medical Issues for participants:________________________________________
_______________________________________________________________________
Please make checks payable to: Holderness Recreation, and mail to Holderness Recreation, PO Box 203, Holderness, NH 03245. Registration deadlines are one week prior to the start date of program. The program fee must be paid in advance to guarantee your placement in a program. Non-residents please add $5 to the Program Fee. Programs without the set minimum number of participants are subject to cancellation.
Any questions, please call Wendy Werner, Holderness Recreation Director, 968-3700 or E-mail: holdrec@adelphia.net.
Holderness Recreation
Release Of All Claims
In consideration of the permission granted for the above named participant to take part in the above named Recreation Program, I here by release for myself and my heirs, the Town of Holderness, its agents, employees, volunteers, and other program participants, from all actions, damages, claims, and negligence, which may result in personal injuries and/or damages.
I recognize there may be inherent dangers in participating in a Recreation Program, which may present strain on the body and its parts, and furthermore, I represent to the best of my knowledge, the participant is in proper physical condition to allow participation. I am aware that there may be transportation, by both bus and private vehicle, that may be necessary for implementation of the activities and / or medical treatment, and therefore give permission for myself and/or son/daughter to be transported as such, and I assume all risks associated with participation in this program.
I understand that, in case of an emergency, Holderness Recreation will attempt to contact the person identified as the “emergency contact”. In the event of a medical emergency, I consent to the participant’s treatment by a medical doctor and I agree to be responsible for all costs associated with said treatment, including transportation to a medical facility.
I the undersigned, here read this release and understand all its terms and implications. I hereby execute this release of my own free will and with full knowledge of its significance.
Signature__________________________________________ Date_______________
Parent Guardian or Participant over 18 years
Printed Name ______________________________________
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