Samuel Recreation Center

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Samuel Recreation Center Registration

Program:

Participant Information

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Age:

* Birthdate:

* Email:

* Gender:

* Grade:

* School:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

EMail:

* Home Phone:

Work Phone:

* Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

Relationship to Participant:

* Insurance Carrier:

* Policy #:

* Shirt Size:

Waiver

My child has permission to participate in the above activity and to be escorted, under proper adult supervision, away from Samuel Recreation Center to participate in activities associated with the event of which I have registered. I do not hold Samuel Recreation Center and program staff responsible for any accident or illness that might occur while my child is involved in scheduled activities. I request that the adult in charge seek or administer proper medical attention if necessary. Participants should have a recent medical examination certifying that his/her physical activity need not be limited. Participants assume any and all risks associated with the activity including, but not limited to falls, contact with other participants, heat or humidity and condition of fields, all such risks being known and appreciated by me. I hereby release the City of Philadelphia, Department of Recreation, all sponsors, agents, volunteers and anyone acting on their behalf for any and all claims of liability.

I/we agree with the above *

* indicates required fields

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Samuel Recreation Center Registration