Brochure - Town of Cumberland

Course Registration FormParticipant First Name Last Name GenderStreet Address City ZipHome Phone Work Phone CellChild’s Age Date of Birth Grade (Current)Parent’s NameE-MailMedical Concerns/Medication/Special NeedsEmergency Contact Emergency Phone Relationship to ParticipantParent’s Signature (for youth program)In consideration of my [and/or my child(s)] participation in this activity, I hereby release and discharge the Town of Cumberland, and its representatives, successors, andassigns, from any and all liability arising from accident, injury, and illness that I (he/she) may suffer as a result of my (our) participation in this activity. I (we) also willfollow the rules and regulations set by the Town of Cumberland and above named parties. I understand that the Town of Cumberland may take pictures or video of thisprogram for promotional purposes. Parent or guardian must sign for anyone age 18 and under.Course NameFeeCourse NameFeeCredit Card Number Exp Date: 3 Digit Code:Course Registration FormParticipant First Name Last Name GenderStreet Address City ZipHome Phone Work Phone CellChild’s Age Date of Birth Grade (Current)Parent’s NameE-MailMedical Concerns/Medication/Special NeedsEmergency Contact Emergency Phone Relationship to ParticipantParent’s Signature (for youth program)In consideration of my [and/or my child(s)] participation in this activity, I hereby release and discharge the Town of Cumberland, and its representatives, successors, andassigns, from any and all liability arising from accident, injury, and illness that I (he/she) may suffer as a result of my (our) participation in this activity. I (we) also willfollow the rules and regulations set by the Town of Cumberland and above named parties. I understand that the Town of Cumberland may take pictures or video of thisprogram for promotional purposes. Parent or guardian must sign for anyone age 18 and under.Course NameFeeCourse NameFeeCredit Card Number Exp Date: 3 Digit Code:31