FACILITY ADDRESSES

BALLENGER CREEK MIDDLE SCHOOL 5525 Ballenger Creek Pike ı Frederick, MD 21703

BALLENGER CREEK PARK Dog Park ı Teaching Kitchen ı Community Building 5420 Ballenger Creek Pike ı Frederick, MD 21703

FCPR MAIN OFFICE - BOURNE BUILDING 355 Montevue Lane ı Frederick, MD 21702

BRUNSWICK BRANCH LIBRARY 915 N Maple Avenue ı Brunswick, MD 21716

BRUNSWICK ELEMENTARY SCHOOL 400 Central Avenue ı Brunswick, MD 21716

CATOCTIN CREEK PARK & NATURE CENTER 2929 Sumantown Road ı Middletown, MD 21769

C. BURR ARTZ PUBLIC LIBRARY 110 East Patrick Street ı Frederick, MD 21701

CENTERVILLE REC CENTER in Centerville Elementary 3601 Carriage Hill Drive ı Frederick, MD 21704

CUNNINGHAM FALLS STATE PARK 14039 Catoctin Hollow Road ı Thurmont, MD 21788

DEER CROSSING REC CENTER in Deer Crossing Elementary 10601 Finn Drive ı New Market, MD 21774

EMMITSBURG COMMUNITY CENTER Emmitsburg Senior Center ı Emmitsburg Library 300 South Seton Avenue ı Emmitsburg, MD 21727

FLIPS 82 Wormans Mill Court ı Frederick, MD 21701

FOUNTAIN ROCK PARK & NATURE CENTER 8511 Nature Center Place ı Walkersville, MD 21793

FREDERICK BOOK ART CENTER, INC. 217 West Patrick Street ı Frederick, MD 21701

FREDERICK COUNTY HEALTH DEPARTMENT 350 Montevue Lane ı Frederick, MD 21702

FREDERICK SENIOR CENTER 1440 Taney Avenue ı Frederick, MD 21702

GEMNASTICS ACADEMY 299 Bucheimer Road ı Frederick, MD 21701

GLADE ELEMENTARY 9525 Glade Road ı Walkersville, MD 21793

KEMPTOWN PARK 3456-B Kemptown Church Rd ı Monrovia, MD 21770

KICK’S KARATE STUDIO Frederick Studio 1700 Kingfisher Drive, St 18 ı Frederick, MD 21701 Urbana Studio 3531 John Simmons Street ı Frederick, MD 21704 Westview Studio 5010 Buckeystown Pk ı Frederick, MD 21704

MIDDLETOWN PUBLIC LIBRARY 101 Prospect Street ı Middletown, MD 21769

MIDDLETOWN HIGH SCHOOL 200 Schoolhouse Drive ı Middletown, MD 21769

MIDDLETOWN PARK 7628 Coblentz Road ı Middletown, MD 21769

MIDDLETOWN REC CENTER in Middletown Primary 403 Franklin Street ı Middletown, MD 21769

MYERSVILLE COMMUNITY LIBRARY 8 Harp Place ı Myersville, MD 21773

MYERSVILLE MUNICIPAL CENTER 301 Main Street ı Myersville, MD 21773

OAKDALE REC CENTER in Oakdale Elementary 5830 Oakdale School Road ı Ijamsville, MD 21754

OTHELLO REGIONAL PARK 1901-A Jefferson Pike ı Knoxville, MD 21758

OLD NATIONAL PIKE PARK 12406 Old National Pike ı Mt. Airy, MD 21771

PINECLIFF PARK Browning Building 8350 Pinecliff Park Road ı Frederick, MD 21704

ROSE HILL MANOR PARK 1611 N. Market Street ı Frederick, MD 21701 SUGARLOAF REC CENTER in Sugarloaf Elementary 3400 Stone Barn Drive ı Frederick, MD 21704

THURMONT REC CENTER in Thurmont Middle 408 E. Main Street ı Thurmont, MD 21788

THURMONT REGIONAL LIBRARY 76 E. Moser Road ı Thurmont, MD 21788

TUSCARORA REC CENTER in Tuscarora Elementary 6321 Lambert Drive ı Frederick, MD 21703

TUSCARORA TENNIS CLUB 5216 Renn Road ı Frederick, MD 21703

URBANA ACADEMY 11791 Fingerboard Road ı Monrovia, MD 21770

URBANA COMMUNITY PARK 3636 Urbana Pike ı Frederick, MD 21704

URBANA DISTRICT PARK 3805 Urbana Pike ı Frederick, MD 21704

URBANA REGIONAL LIBRARY 9020 Amelung Street #7006 ı Frederick, MD 21704

UTICA DISTRICT PARK 10200-B Old Frederick Road ı Frederick, MD 21702

WALKERSVILLE HIGH SCHOOL 81 W. Frederick Street ı Walkersville, MD 21793

WALKERSVILLE BRANCH LIBRARY 57 West Frederick Street ı Walkersville, MD 21793

WALKERSVILLE REC CENTER in Walkersville Elementary 83 West Frederick Street ı Walkersville, MD 21793

WEST WINDS TENNIS CENTER 11411 Gas House Pike ı New Market, MD 21774

WHISKEY CREEK GOLF COURSE 4804 Whiskey Court ı Ijamsville, MD 21754

YELLOW SPRINGS ELEMENTARY 8717 Yellow Springs Road ı Frederick, MD 21702

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 E-mail Address

Address City State Zip Code

Emergency Contact’s Name Emergency Phone

Program Registration

Participant’s Name Gender DOB Program Name Program # Fee

TOTAL 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: Date: (Parent /Guardian’s signature if participant is under 18 years of age)