Author: jseastrom

Willard Parks And Recreation
______________________________________________________________________________________________________________________
(Program)

OFFICE USE ONLY
Receipt#: ______________
Check#:________
Date: ____________
Circle: Cash CC
Payment Amount: _________

Child’s Name
Gender		Age		Grade
School Attending
Parent/Guardian Name
Home Address
Preferred Contact Number
Alternate Contact Number
E-Mail:
List Special Accommodations for participant: _______________ _______________ _______________
May your child be photographed for future media purposes? Yes / No
How did you hear about the program? _____________________________

My family and I hereby waive and release Willard Parks and Recreation and its representatives from claims for damages and/or injuries incurred while participating in or as a spectator of Willard Parks and Recreation activities.
X_______________________________________________________
Print Name
X_______________________________________________________ Signature of participant or parent if participant is under 18

For Office use Only