Keiki Triathlon Flyer and Registration Form 2014

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COUNTY OF HAWAII DEPARTMENT OF PARKS AND RECREATION REGISTRATION FORM / CONSENT / RELEASE OF CLAIMS Date Form Filled Out 20 DISTRICT West Hawaii EVENT DATE Oct. 18, 2014 FACILITY Maka'eo Park & Kona Community Aquatic Center SPORT/ACTIVITY 2014 Keiki Triathlon AGE GROUP Please circle one: 7-8 yr. 9-10 yr. 11-12 yr. 13-14 yr. PARTICIPANT'S NAME GENERAL INFORMATION (Please Print) (Last) (First) (Ml) AGE BIRTHDATE PARENT/LEGAL GUARDIAN PHONE (home) (Last) (First) (Ml) MAILING ADDRESS SCHOOL PHONE PHONE GRADE (work) (cell) 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 disability to effectively participate in our program? Please Check One: YES NO L� If yes, please complete a Modification Request with our Recreation Specialist, ph. 961-8740 ext .24, TTY 961-8736. 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 Hawaii, 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 Hawaii, State of Hawaii, 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. I also agree: 1. I 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 (Age 18 or Older) Printed Name of Witness Phone Number Address City Zip Code Rev 5/23-06 Signature of Parent or Legal Guardian Possession or consumption of alcohol by persons under 21 is prohibited. County of Hawaii is an Equal Opportunity Provider and Employer