BIDDEFORD RECREATION DEPARTMENT

PROGRAM PARTICIPANT REGISTRATION FORM

207-283-0841 www.biddefordrec.com

__________________________________________________________ Date of Birth:___/___/___

Name of Adult Participant –or- Name of Parent or Guardian of Child Participant (please print)

Pronouns: She/Her_____He/Him_____They/ Theirs______Other___________________________

Mailing Address:____________________________________________________ Zip:____________

Street	City

Primary Phone: home/cell/work______________________ Second Phone:______________________

E-mail Address:______________________________________________________________________

Emergency Contact:____________________________________ Phone#________________________

Medical / Inclusion Information:__________________________________________________________________

Please provide any prevailing medical conditions or information that would be helpful for us to know in order to provide you and/ or your child with the most positive experience in our programs.

Name of Program(s)___________________________________________________________________

CHILD PARTICIPANT INFORMATION if applicable

Name of Participant: _______________________________________ School: ____________________________

Pronouns: She/Her_____He/Him_____They/ Thiers______Other____________________________________________

Date of Birth: _____/_____/_________ Age:_________________ Grade:________________________________

Medical / Inclusion Information:__________________________________________________________________

Please provide any prevailing medical conditions or information that would be helpful for us to know in order to provide you and/ or your child with the most positive experience in our programs

RELEASE

I understand there are risks of physical injury in participating in sports and recreational activities or programs.
I hereby release the City of Biddeford, its employees, officials and agents from any and all liability, loss, or damage to personal property that, my child or I may experience in connection with activities sponsored by Biddeford Recreation Department.
I hereby consent to emergency medical procedures deemed advisable for my child in the event I cannot be reached and my child has sustained an injury. The Dept. does not provide accident or hospitalization insurance for participants of its programs. All participants are advised to have adequate personal coverage. Please consider participant's own health, experience, and tolerance for risk before participating in any program. I also consent to the use of me or my child’s photo, video, artwork etc. by the dept. for flyers, presentations etc.

This release and consent shall remain in full force and effect for all future recreational activities and programs until revoked in writing by registrant.

____________________________________	_______________

Signature	Date

____________________________________

Name Printed	Rev 2/2024