City of Newburgh REC Activity Registration Form

1. City of Newburgh RECActivity Registration Form Circle one: Kickball Basketball Baseball Soccer Other ____________ Name: ____________________________________ Gender: Male Female Age: __________ Grade: __________ Birthday: ________________ Address: _____________________________________________________________ City: ________________________ State: _______ Zip Code: ____________ Home Phone: ______________________ Cell Phone: ____________________ e-mail:_________________________________________Parent’s Name: __________________________________________ Emergency Contact: Name: ___________________ Phone #: _______________ Informed Consent – Must be signed by parent/guardianI declare that my child is in good physical condition and has no ailments that would prevent participation in the recreational activitiesoffered by the City of Newburgh Recreation Department. I understand that my child’s participation in recreational activities may involve strenuous physical activity. I acknowledge that injuries or other complications associated with exercise or physical activity may result from my child’s participation. In exchange for permission for my child to participate in the recreational activity, I knowingly agree to waive and release from any and all claims and causes of action that I may acquire against the City of Newburgh, its trustees, officers, employees, or agents thereof for any and all injuries, loss or damage which my child may suffer or which are in any way connected with my child’s participation in the City of Newburgh Recreational Program. I agree to allow my child to be photographed and/or videotaped by City of Newburgh staff or their designee and for those photos and/or videos to be used for the advertising and promotion of City of Newburgh recreational activities. I hereby forever release and discharge the City of Newburgh from any and all claims, actions and demands arising out of or in connection with the use of said photographs or videos, including, without limitation, any and all claims for invasion of privacy and libel. This release shall inure to the benefit of the assigns, licensees and legal representatives of the City of Newburgh.I acknowledge that I am registering my child for a City of Newburgh recreational activity. ________________________________________Parent/Guardian Signature