Recreation Program Registration form - REC- 1003 - City Of St. John's

REC-1003
Community Services Department, Recreation Division
RECREATION PROGRAM REGISTRATION FORM
Please complete both sides of this form in full and print clearly. In order for your child to be accepted
into the program, this form must be forwarded seven days prior to the start of the program to
recreation@stjohns.ca or in person to the Wedgewood Park Recreation Centre, 47 Gleneyre Street, or the
H.G.R. Mews Community Centre, 40 Mundy Pond Road.
PARTICIPANT INFORMATION: If under the age of 19 this application must be completed by a parent or guardian. SECTION 1
Last Name: ________________________________________ First Name: ______________________________________ Middle Initial: ________
Male Female Date of Birth (yyyy-mm-dd): __________________________________________________________________________
Street Address: ______________________________________________________________________________________________________
City/Town: _______________________________________________ Postal Code: ____________________________________________
Telephone: (home): ____________________________ (work): __________________________ (cell): ____________________________
E-mail Address: ______________________________________________________________________________________________________
GUARDIAN 1 INFORMATION:(Primary Contact) GUARDIAN 2 INFORMATION:(Alternate Contact) EMERGENCY CONTACT: SECTION 2
First Name: ___________________________
Last Name: ___________________________
Relationship to Participant: _______________
Home Phone: _________________________
Business Phone: _______________________
Cell or Pager: _________________________
E-mail: _______________________________
First Name: ____________________________
Last Name: ____________________________
Relationship to Participant: ________________
Home Phone: __________________________
Business Phone: ________________________
Cell or Pager: ___________________________
E-mail: ________________________________
First Name: __________________________
Last Name: __________________________
Relationship to Participant: ______________
Home Phone: _________________________
Business Phone: _______________________
Cell or Pager: _________________________
E-mail: ______________________________
AUTHORIZED PERSONS: Please list any person(s) other than those listed above who are authorized to pick up your child from
the program site. Please Note: Children will only be released to authorized persons.
SECTION 3
Name Relationship to Child Phone Number Alternate Phone Number (Cell)
PROGRAM INFORMATION: Please complete one line for each program you are registering for. SECTION 4
Name of Program
Location/Facility
MEDICAL INFORMATION: SECTION 5
Does the participant have any special needs or medical concerns (such as an allergy or disability) which may impact their ability to participate?
Yes No If yes, please list: _______________________________________________________________________________________
Will the participant be taking medication during the program? Yes No Does your child carry an Epi-Pen? Yes No
If you have answered yes to any of the questions above, please contact our Inclusive Services Team at (709) 576-4450 or (709) 576-2574 or
e-mail recreation@stjohns.ca to acquire additional information and/or applicable forms.
Form last updated: Date (2013/04/17) Page 1 of 2

REC-1003
Community Services Department, Recreation Division
DECLARATION: SECTION 6
IMPORTANT NOTICE - MUST READ
By signing below, I am acknowledging and agreeing to be bound by the Waiver of Liability, Indemnity and Defence, Medical Authorization and the
Refund Policy found below. I also acknowledge that I have read and understand the participant information package, including the Behaviour
Guidelines (available at: http://www.stjohns.ca/living-st-johns/recreation-and-parks/childrens-programs). I agree to provide the required information
to the Recreation Division as it relates to me and my family members.
WAIVER AND RELEASE OF ALL CLAIMS
I acknowledge that I have read this form carefully. I agree that by registering and participating in, or registering my minor child/ward for and allowing
his/her participation in the programs (the "Program"), that I am WAIVING and RELEASING all claims for myself and my minor child/ward arising out
of such registration and participation. In consideration of the City of St. John's (the "City") accepting me and/or my minor child/ward as a participant
in the Program, I hereby acknowledge and assume the risk of injury and/or loss. I have fully informed myself of all of the details of the Program and
the risks inherent in the Program. I believe and represent that I and/or my minor child/ward have the necessary abilities, skills, and knowledge to
participate in the Program. I recognize and acknowledge that the Program involves risks of bodily injury, death and property loss. I hereby agree to,
and do, assume the full risk of any injuries, including death, any property loss and all expenses, costs, damages and losses that I, or my minor
child/ward may sustain as a result of participating in any and all activities connected with or associated with the Program. I hereby agree to, and do,
waive, release and relinquish all claims, demands, rights of action, damages, liabilities and controversies of every kind, known and unknown,
present and future, that I, or my minor child/ward may have against the City and its officers, agents, servants, employees, insurers, related or
affiliated individuals or entities, successors and assigns arising out of, connected with, or in any way related to my or my minor child/ward's
participation in the Program.
INDEMNITY AND DEFENCE
I hereby agree to indemnify and hold harmless and defend the City and its officers, agents, servants, employees, insurers, related or affiliated
individuals or entities, successors and assigns from any and all claims, lawsuits, demands, damages, liabilities, losses and expenses, including
attorney's fees and administrative expenses, of every kind, known and unknown, present and future, arising out of, connected with, or in any way
related to my own or my minor child/ward's participation in the Program.
MEDICAL AUTHORIZATION/EMERGENCY CARE
In the event of an emergency, I authorize and give permission to the City to have staff administer or arrange for any emergency medical care
including hospitalization and/or transportation if necessary for any medical treatment deemed reasonable and necessary in the circumstances for
myself and/or my minor child/ward's immediate care and I consent on behalf of myself and my child/ward to the administration of such medical
treatment. I agree that I will be responsible for the cost and payment of any and all such treatment rendered.
REFUND POLICY
A refund will be issued if requested 14 days prior to the start date of the program or 14 days prior to the start date for Birthday parties – (does not
include the $25 day camp deposit). After that, a refund or credit may be issued for a medical reason which prohibits participation in the program. A
medical note must accompany the refund form. Refunds or credits will not be issued for classes missed due to illness; lost/stolen passes or
memberships or requests submitted after the program end date. Completion of the application does not automatically guarantee a refund.
Parent/Guardian Name:
___________________________________________________
Parent/Guardian Signature: ___________________________________________________ Date (yyyy-mm-dd) ______________________
FOR OFFICE USE ONLY: SECTION 7
Received: Online: Other: Date: _____________________________________
Received/Reviewed by C.D. / F & LS Staff: ________________________________________ Date: _____________________________________
Reviewed by Inclusive Services Staff: ____________________________________________ Date: _____________________________________
Please send completed form to:
CC
City of St. John’s
Department of Recreation
P.O. Box 908, St. John’s, NL
A1C 5M2
or drop off at any of the following locations:
H.G.R. Mews Community Centre, 40 Mundy Pond Road
Wedgewood Park Recreation Centre, 47 Gleneyre Street
Department of Recreation Offices, Crosbie Building, 1 Crosbie Place
Or Fax: (709) 576-8146
Form last updated: Date (2013/04/17) Page 2 of 2