2024 PR Track and Field Program (Packet: Letter, Reminders, Age Group Entry Form, Exponent Entry Form and Registration Form)

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DISTRICT SPORTIACTIVITY. COUNTY OF HAWAI'I DEPARTMENT OF PARKS AND RECREATION REGISTRATION FORM I CONSENT I RELEASE OF CLAIMS Date Form Fliled Out 120 GENERAL INFORMATION (Please PiMQ AGE GROUP PARTICIPANT'S NAME AGE BiRTHDATE= flaat). (First) PARENT/LEGAL GUARDIAN PHONE (home) (Last) (Forst! IMt) MAILING ADDRESS PHONE (work) PHONE (cell) SCHOOL GRADE HEALTH & EMERGENCY INFORMATION PLEASE LET US KNOW ANY MEDICAL INFORMATION RELEVANTTO THE CARE OF YOUR CHiLU; CHILD'S DOCTOR PHONE HEALTH PLAN EMERGENCY CONTACTS other than parentlguardion listed above, NAME PHONE RELATIONSHIP, NAME PHONE _ RELATIONSHIP We are committed to making our recreation programs accessible, Does your child need modifications due to a & disability to effectively participate in our program? Please Check One.' YES NO If yes, please complete a Modification Request with our Recreation Speciefist, ph.. 961-9581 Adult attendants or skills trainers who accompany a child in our P&R programs must register belor4 the first day of the program. MEDIA RELUSg uWe Hereby give permission to the Department of Parks & Recreation, County of Hawal'i, to allow the news media to film and photograph program activities provided: t) They are for news and non-commafdal purposes; 2) The program direrlar determines the filming, a1e., writ not unduly interfere with or disturb the programs; and 3) Individual chili dren are not singled oul for demonstrating photography or interview purposes against their wishes. Please ChaCk One: YES, permission granted NO, permission denied (If no horn Is checked, assumption. is -No, permission denied') CONSENT In consideration of the permission granted to me by the County of Hawaii, State of Hawai'i, for my minor child ("Child") to participate in the above -mentioned sportlactivity ("Activity'), the above -named PARENTILEGAL GUARDIAN ("Parent') consents and agrees that: a. Child is allowed to actively participate in Activity; h. Child is participating voluntarily- and with Parent's approval and consent. c. Child is in reasonably good physical and mental health, such that Minor can safely participate in Activity, d. Parent recognizes and understands that participation in the Activity involves risk of death, personal injury and/or property damages, commonly inherent in such Activity. e. Parent shall notify a representative from the Department of Parks and Recreation if there is any change in Child's physical and/or mental condition such that MINOR cannot safely participate in Activity. f. The Department of parks & Recreation may refer Child, if injured or ill, to my family doctor when I cannot be reached. When there is no family doctor, the Department has the discretion to select a doctor. i also agree: 1, f have read BOTH SIDES of this registration form, including the Informed Consent, Assumption of Risks, Code of Conduct, and Release of Claims on the back side of this page, 2. 1 understand and agree with all of its terms. 3. 1 have filled out the information on this form fully and completely. 4. 1 will notify the County immediately in writing of any changes to the information above. 5, 1 am signing this form voluntarily and with full knowledge of its significance. IN WITNESS WHEREOF, I have executed this Registration, Consent and Assumption of Risks, Release of Claims and indemnification and Code of Conduct at on the day and year first written above. (Place of Execution) Signature of Witness (Ape 18 or O)der) Feinted Name & Mrtness Phone Number Address City zip Cote Signature of Pared! or Legal Guardian Possession or consumption of alcohol by persons under 21 is prohibited. County of Hawnll is an Equal opportunity Providerand Employer Rev &23-d6, 8112