GBSA

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Registration

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

State:

Zip Code:

* Home Phone:

* Birthdate:

* Email:

* Gender:

* Grade:

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 Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

IMPORTANT INFORMATION

The Town of Grant is committed to conducting its recreation program and activities in the safest manner
possible and holds the safety of participants in the highest possible regard. Participants and parents
registering their child must recognize however, that there is an inherent risk of injury when choosing to
participate in recreation activities. The Town of Grant continually strives to reduce such risks and insist
that all participants follow safety rules and instructions that have been designed to protect the
participant's safety.

Please recognize that the Town of Grant does not carry medical accident insurance for injuries sustained
in its programs. The cost of such would make program fees prohibitive. Therefore, each person registering
himself or herself or a family member for a certain program/activity should review his or her own health
insurance policy for coverage. It must be noted that the absence of health coverage does not make the
Town of Grant automatically responsible for the payment of medical expenses.

Due to the difficulty and high cost of obtaining liability insurance, the agency providing liability coverage
for the Town of Grant requires the execution of the following Waiver and Release. Your cooperation is
greatly appreciated.

WAIVER AND RELEASE OF ALL CLAIMS
SUMMER PROGRAM

As a parent/guardian of a participant in the program, I recognize and acknowledge that there are certain
risks of physical injury and agree to assume the full risk of any injuries, (including death)*, damages or
loss which I or my minor chi1d/ward may sustain as a result of participating in any and all activities
connected with or associated with such program.

I agree to waive and relinquish all claims my minor child/ward or I may have as a result of participating
in the program against the Town of Grant and its officers, agents, servants, and employees.

I do hereby fully release and discharge the Town of Grant and its officers, agents, servants, and employees
from any and all claims from injuries, (including death)*, damage or loss which I or my minor child/ward
may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in
any way associated with the activities of the program.

I further agree to indemnify and hold harmless and defend the Town of Grant and its officers, agents,
servants and employees from any and all claims resulting from injuries, (including death)*, damages and
losses sustained by me or my minor child arising out of, connected with, or in any way associated with
the activities of the program.

In the event of any emergency, I authorize the Town of Grant officials to secure from any licensed hospital,
physician, and/or medical personnel any treatment deemed necessary for my minor child's immediate
care and agree that I will be responsible for payment of any and all medical services rendered.

I have read and fully understand the above Program Details, Waiver and Release of All Claims and
Permission to Secure Treatment.

* “ including death” may be excluded

I/we agree with the above *

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