Recreation Program Registration form - REC- 1003 - City Of St. John's
Recreation Program Registration form - REC- 1003 - City Of St. John's
Recreation Program Registration form - REC- 1003 - City Of St. John's
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<strong>REC</strong>-<strong>1003</strong><br />
Community Services Department, <strong>Recreation</strong> Division<br />
<strong>REC</strong>REATION PROGRAM REGISTRATION FORM<br />
Please complete both sides of this <strong>form</strong> in full and print clearly. In order for your child to be accepted<br />
into the program, this <strong>form</strong> must be forwarded seven days prior to the start of the program to<br />
recreation@stjohns.ca or in person to the Wedgewood Park <strong>Recreation</strong> Centre, 47 Gleneyre <strong>St</strong>reet, or the<br />
H.G.R. Mews Community Centre, 40 Mundy Pond Road.<br />
PARTICIPANT INFORMATION: If under the age of 19 this application must be completed by a parent or guardian. SECTION 1<br />
Last Name: ________________________________________ First Name: ______________________________________ Middle Initial: ________<br />
Male Female Date of Birth (yyyy-mm-dd): __________________________________________________________________________<br />
<strong>St</strong>reet Address: ______________________________________________________________________________________________________<br />
<strong>City</strong>/Town: _______________________________________________ Postal Code: ____________________________________________<br />
Telephone: (home): ____________________________ (work): __________________________ (cell): ____________________________<br />
E-mail Address: ______________________________________________________________________________________________________<br />
GUARDIAN 1 INFORMATION:(Primary Contact) GUARDIAN 2 INFORMATION:(Alternate Contact) EMERGENCY CONTACT: SECTION 2<br />
First Name: ___________________________<br />
Last Name: ___________________________<br />
Relationship to Participant: _______________<br />
Home Phone: _________________________<br />
Business Phone: _______________________<br />
Cell or Pager: _________________________<br />
E-mail: _______________________________<br />
First Name: ____________________________<br />
Last Name: ____________________________<br />
Relationship to Participant: ________________<br />
Home Phone: __________________________<br />
Business Phone: ________________________<br />
Cell or Pager: ___________________________<br />
E-mail: ________________________________<br />
First Name: __________________________<br />
Last Name: __________________________<br />
Relationship to Participant: ______________<br />
Home Phone: _________________________<br />
Business Phone: _______________________<br />
Cell or Pager: _________________________<br />
E-mail: ______________________________<br />
AUTHORIZED PERSONS: Please list any person(s) other than those listed above who are authorized to pick up your child from<br />
the program site. Please Note: Children will only be released to authorized persons.<br />
SECTION 3<br />
Name Relationship to Child Phone Number Alternate Phone Number (Cell)<br />
PROGRAM INFORMATION: Please complete one line for each program you are registering for. SECTION 4<br />
Name of <strong>Program</strong><br />
Location/Facility<br />
MEDICAL INFORMATION: SECTION 5<br />
Does the participant have any special needs or medical concerns (such as an allergy or disability) which may impact their ability to participate?<br />
Yes No If yes, please list: _______________________________________________________________________________________<br />
Will the participant be taking medication during the program? Yes No Does your child carry an Epi-Pen? Yes No<br />
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<br />
e-mail recreation@stjohns.ca to acquire additional in<strong>form</strong>ation and/or applicable <strong>form</strong>s.<br />
Form last updated: Date (2013/04/17) Page 1 of 2
<strong>REC</strong>-<strong>1003</strong><br />
Community Services Department, <strong>Recreation</strong> Division<br />
DECLARATION: SECTION 6<br />
IMPORTANT NOTICE - MUST READ<br />
By signing below, I am acknowledging and agreeing to be bound by the Waiver of Liability, Indemnity and Defence, Medical Authorization and the<br />
Refund Policy found below. I also acknowledge that I have read and understand the participant in<strong>form</strong>ation package, including the Behaviour<br />
Guidelines (available at: http://www.stjohns.ca/living-st-johns/recreation-and-parks/childrens-programs). I agree to provide the required in<strong>form</strong>ation<br />
to the <strong>Recreation</strong> Division as it relates to me and my family members.<br />
WAIVER AND RELEASE OF ALL CLAIMS<br />
I acknowledge that I have read this <strong>form</strong> carefully. I agree that by registering and participating in, or registering my minor child/ward for and allowing<br />
his/her participation in the programs (the "<strong>Program</strong>"), that I am WAIVING and RELEASING all claims for myself and my minor child/ward arising out<br />
of such registration and participation. In consideration of the <strong>City</strong> of <strong>St</strong>. <strong>John's</strong> (the "<strong>City</strong>") accepting me and/or my minor child/ward as a participant<br />
in the <strong>Program</strong>, I hereby acknowledge and assume the risk of injury and/or loss. I have fully in<strong>form</strong>ed myself of all of the details of the <strong>Program</strong> and<br />
the risks inherent in the <strong>Program</strong>. I believe and represent that I and/or my minor child/ward have the necessary abilities, skills, and knowledge to<br />
participate in the <strong>Program</strong>. I recognize and acknowledge that the <strong>Program</strong> involves risks of bodily injury, death and property loss. I hereby agree to,<br />
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<br />
child/ward may sustain as a result of participating in any and all activities connected with or associated with the <strong>Program</strong>. I hereby agree to, and do,<br />
waive, release and relinquish all claims, demands, rights of action, damages, liabilities and controversies of every kind, known and unknown,<br />
present and future, that I, or my minor child/ward may have against the <strong>City</strong> and its officers, agents, servants, employees, insurers, related or<br />
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<br />
participation in the <strong>Program</strong>.<br />
INDEMNITY AND DEFENCE<br />
I hereby agree to indemnify and hold harmless and defend the <strong>City</strong> and its officers, agents, servants, employees, insurers, related or affiliated<br />
individuals or entities, successors and assigns from any and all claims, lawsuits, demands, damages, liabilities, losses and expenses, including<br />
attorney's fees and administrative expenses, of every kind, known and unknown, present and future, arising out of, connected with, or in any way<br />
related to my own or my minor child/ward's participation in the <strong>Program</strong>.<br />
MEDICAL AUTHORIZATION/EMERGENCY CARE<br />
In the event of an emergency, I authorize and give permission to the <strong>City</strong> to have staff administer or arrange for any emergency medical care<br />
including hospitalization and/or transportation if necessary for any medical treatment deemed reasonable and necessary in the circumstances for<br />
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<br />
treatment. I agree that I will be responsible for the cost and payment of any and all such treatment rendered.<br />
REFUND POLICY<br />
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<br />
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<br />
medical note must accompany the refund <strong>form</strong>. Refunds or credits will not be issued for classes missed due to illness; lost/stolen passes or<br />
memberships or requests submitted after the program end date. Completion of the application does not automatically guarantee a refund.<br />
Parent/Guardian Name:<br />
___________________________________________________<br />
Parent/Guardian Signature: ___________________________________________________ Date (yyyy-mm-dd) ______________________<br />
FOR OFFICE USE ONLY: SECTION 7<br />
Received: Online: Other: Date: _____________________________________<br />
Received/Reviewed by C.D. / F & LS <strong>St</strong>aff: ________________________________________ Date: _____________________________________<br />
Reviewed by Inclusive Services <strong>St</strong>aff: ____________________________________________ Date: _____________________________________<br />
Please send completed <strong>form</strong> to:<br />
CC<br />
<strong>City</strong> of <strong>St</strong>. John’s<br />
Department of <strong>Recreation</strong><br />
P.O. Box 908, <strong>St</strong>. John’s, NL<br />
A1C 5M2<br />
or drop off at any of the following locations:<br />
H.G.R. Mews Community Centre, 40 Mundy Pond Road<br />
Wedgewood Park <strong>Recreation</strong> Centre, 47 Gleneyre <strong>St</strong>reet<br />
Department of <strong>Recreation</strong> <strong>Of</strong>fices, Crosbie Building, 1 Crosbie Place<br />
Or Fax: (709) 576-8146<br />
Form last updated: Date (2013/04/17) Page 2 of 2