Township Sponsored Program Registration Form

ONLINE Program Registration Form

PARTICIPANT(S) INFORMATION

Full Name *

Age *

(if under 18)

Full Name *

Age *

(if under 18)

Street Address *

Town *

Province *

Postal Code *

Home Phone *

Work Phone

Email address *

Some programs involve physical activity. Do you have a health issue we should be made aware of? *

Yes

If so, what is it? *

Do you have your Doctor’s permission to participate? *

Yes

Please identify if you have any allergies *

IF PARTICIPANT IS UNDER THE AGE OF 18

Parent/Guardian *

Home Phone *

Work Phone *

Email *

Emergency Contact *

Home Phone *

Work Phone *

PROGRAM INFORMATION

Program *

Date(s) Offered *

Location *

Permission to Photograph/Video

By signing this registration form, I give permission for the Township of Rideau Lakes to take pictures/videos of myself and/or family members that may be used in future publications and/or on the Township’s website for the purpose of promoting the day camp/recreational activities, and sharing camp memories with families, understanding that the person(s) photographed/videoed will not be identified by name.

Signature *

Date

Waiver:

By signing this registration form, I understand that there are risks involved in participating in any activity or program and I acknowledge that my choice to participate or register myself or my children in the above mentioned activity or program brings with it the assumption by me of those risks. I am aware of no physical or other reason why the above named person should not participate in this program. I do hereby release the Township of Rideau Lakes and its employees and agents from any claim whatsoever arising from my participation or from my children’s participation in any program as stated above, or in any facility or location where the program is held.

Signature *

Date

Phone

Refunds: Requests for refunds must be received at least 5 days prior to the start of the program. A cancellation fee of 25% of the total registration will be charged. Exceptions may be made on a pro-rata basis for certified medical reasons.