2014 Track & Field Program (Letter, Reminders and Registration Forms)

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COUNTY OF HAWAI`I DEPARTMENT OF PARKS AND RECREATION REGISTRATION FORM / CONSENT / RELEASE OF CLAIMS Date Form Filled Out _______________, 20____ DISTRICT____________________________________FACILITY_____________________________________________ SPORT/ACTIVITY______________________________________________________ AGE GROUP_________________ GENERAL INFORMATION (Please Print) PARTICIPANT’S NAME _____________________________________________ AGE_____ BIRTHDATE_____________ (Last) (First) (MI) PARENT/LEGAL GUARDIAN_________________________________________ PHONE____________________ (home) (Last) (First) (MI) MAILING ADDRESS ________________________________________________PHONE_____________________(work) ________________________________________________PHONE_____________________ (cell) SCHOOL _________________________________________________________GRADE_________________________ HEALTH & EMERGENCY INFORMATION PLEASE LET US KNOW ANY MEDICAL INFORMATION RELEVANT TO THE CARE OF YOUR CHILD: ____________________________________________________________________________________________________________ CHILD’S DOCTOR _________________________________ PHONE _________________ HEALTH PLAN _____________________ EMERGENCY CONTACTS other than parent/guardian 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 Please Check One: disability to effectively participate in our program? _____ YES _____ NO If yes, please complete a Modification Request with our Recreation Specialist, ph. 961-8681. Adult attendants or skills trainers who accompany a child in our P&R programs must register before the first day of the program. MEDIA RELEASE I/We hereby give permission to the Department of Parks & Recreation, County of Hawai`i, to allow the news media to film and photograph program activities provided: 1) They are for news and non-commercial purposes; 2) The program director determines the filming, etc., will not unduly interfere with or disturb the programs; and 3) Individual children are not singled out for demonstrating photography or interview purposes against their wishes. Please Check One: _____ YES, permission granted _____ NO, permission denied (If no box is checked, assumption is “No, permission denied”) CONSENT In consideration of the permission granted to me by the County of Hawai`i, State of Hawai`i, for my minor child (“Child”) to participate in the above-mentioned sport/activity (“Activity”), the above-named PARENT/LEGAL GUARDIAN (“Parent”) consents and agrees that: a. Child is allowed to actively participate in Activity; b. 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. BOTH SIDES I also agree: 1. I have read 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. I understand and agree with all of its terms. 3. I have filled out the information on this form fully and completely. 4. I will notify the County immediately in writing of any changes to the information above. 5. I 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 (Age 18 or Older) Signature of Parent or Legal Guardian __________________________________________ Printed Name of Witness Phone Number __________________________________________ Address City Zip Code Possession or consumption of alcohol by persons under 21 is prohibited. County of Hawai‘i is an Equal Opportunity Provider and Employer Rev 5/23-06, 8/12