Registration Form Frederick County Parks and Recreation 355 Montevue Ln, Suite 100, Frederick, Maryland 21702 Phone: 301-600-2936 • Fax: 301-600-2595
Full Name of Payee
Phone
Address
E-mail Address
City
State
Emergency Contact’s Name
Zip Code
Emergency Phone
Program Registration Participant’s Name
Gender
DOB
Program Name
Program #
TOTAL FEE
Fee
$
Confirmation is sent via e-mail for online registrations. Otherwise we only notify you if there is a problem or change. Therefore, if it is almost time for your program and you have not heard from us...That's good news.
Medical Conditions Participant
Medical Condition (including allergies) if applicable
Payment □ Cash □ Check or Money Order (make checks payable to Frederick County Treasurer) □ Credit Card (To register by credit card, please go to www.recreater.com or call our main office at 301-600-2936)
Participant Agreement: All participants/guardians must read and sign this waiver form in order to participate. By my signature below, I acknowledge that there are inherent risks and dangers associated with recreation program/s and therefore, I hold Frederick County, Maryland harmless from all claims for injuries, damage, or loss which may result from me or my child’s participation in the program/s listed above. I consent to Frederick County, Maryland’s use of the participant’s image and likeness as shown in any photographs, videotapes, motion picture film, or electronic images, and any audio recordings made of the participant’s voice in whatever way the County desires, including television, print and Internet websites. Furthermore, I consent that such photographs, films, recordings, electronic images shall be the sole property of Frederick County, Maryland. I understand that via the registration process I have the option to submit a non-consent for the use of images of myself or my child during online registration or by calling 301-600-2936. I understand that the Division has a discipline policy for conduct in recreation programs and facilities. I agree to follow the Division’s Code of Conduct. In the event I/my child violate the Code of Conduct and I/my child are asked to leave the program or facility, I understand that the registration fee will not be refunded. I understand that county employees are not responsible for program participants prior to, or after, a scheduled program. I understand that completing the registration process for youth sports programs requires and includes my review of the information on concussions and concussion awareness. This information is available at www.recreater.com/concussion. I understand that I must review the concussion awareness information prior to the first session in order to comply with the state law. I understand that if I am unable to review the concussion awareness information online, that I must request a written copy from the Division of Parks & Recreation by calling 301-600-2936.
Signature: (Parent /Guardian’s signature if participant is under 18 years of age)
Frederick County Parks and Recreation
Date:
www.recreater.com • 301-600-2936
2020 SPRING RECREATER
67
