VIEWS: 2 PAGES: 4 POSTED ON: 4/17/2014
Junior Lifeguard Program PLEASE PRINT AND COMPLETE Registration 2013 Participant Information: Page - 1 Participant Name: Participant D.O.B: / / Participant Address: Postal Code: Parent/Guardian Information: Parent/Guardian Name(s): Relationship to participant: Telphone (Home): Telephone (Cell): Email Address: Junior Lifeguard Program Registration Fees $75.00 Includes Junior Lifeguard T-Shirt. Please tick which size Junior Lifeguard T-Shirt you would like: Childrens Small Adult Small Childrens Medium Adult Medium Childrens Large Adult Large Childrens X-Large We accept cash and cheques at the Swimming Pool. Cheques are to be made out to the Town of Shellbrook. You can also pay for fees at the Town Office where cash, cheques and debit is accepted. Official Use Only: Payment Due : $75.00 Method of Payment: Cash Chq & # Receipt# Medical Information: Please indicate below if the participant has any medical issues or medication requirements that the we should be aware of? (i.e. diabetes, epilepsy, allergies….etc.) Please List: Emergency Contact Name (If different from Parent/Guardian): Contact No: Health Card Number: Please Turn Page Junior Lifeguard Program PLEASE PRINT AND COMPLETE Registration 2013 Page - 2 Release and Waiver of Claim: Please read, complete and sign. (Please Print) I, , parent/legal guardian of child, hereby acknowlege and agree that in consideration of his/her being permitted to participate in the Junior Lifeguard Program offered by the Town of Shellbrook: i. I understand and acknowledge the risks inherent with the activites carried out during the program, and hereby accept and assume all such risks which I or the participating youth for whom I act as guardian may be exposed. ii. I am sufficiantly informed to represent to the Town that the participant does not suffer any condition that may affect his/her ability to safely participate in the program. I also acknowlege that the town reserves the right to required medical certificate in respect to my or his/her ability to participate. iii. I have carefully read and understand clearly that by signing this Release and Waiver of Claim, I will be forever prevented from suing against the Town of Shellbrook or any employee, agent, Parks Board member or officer thereof for any propery loss, or personal injury that I or the youth may suffer while participating in the program. iv. I also acknowledge that the Town of Shellbrook would not permit me or him/her to participate unless I signed the Release and Waiver of Claim and agreed to comply with the rules and regulations as set out by the Town of Shellbrook. Date: Signature: Witness: Photograph Release Declaration: Please read, complete and sign. (Please Print) I, , parent/guardian of participant, grant Shellbrook Swimming Pool the right to take photographs of named participant. I authorize Shellbrook Swimming Pool to copyright, use and publish in print and/or electronically. I agree that Shellbrook Swimming Pool may use such photographs of the named participant with or without identificatio for any lawful purpose, including for example publicity, illustration, advertising and Web content. I have read and understand the above statements: Signature: Printed Name: Date: Junior Lifeguard Program PLEASE PRINT AND COMPLETE Registration 2013 aware of? Junior Lifeguard Program PLEASE PRINT AND COMPLETE Registration 2013 uard hat may program. signed imming ntification
"Junior Lifeguard Program Registration 2013 - Town of Shellbrook"