Registration and Waiver Form

Participant's Name:                                                                               
Parent's Name:                                                                               
Address:                                                                            
City:                                     Zip:                       Age, if under 18:                
Phone #: (h)                                      w)                                           

In case of Emergency - person should be available during program hours

 

Name                                Relationship                              Phone
Activity Day and Time of Class Fee
     
     
     
# of classes___________ Amount Paid________ Receipt #__________

I hereby accept all responsibility for and will not hold the Charter Township of Van Buren, Van Buren Township Board or Trustees and/or Van Buren Parks and Recreation Department or its employees liable for any loss, damage, or injury to property or person as a result of involvement in Van Buren Township's Recreation  Classes or Programs.

In the event of sudden illness, accident, or injury which may occur while myself or my child is participating in an activity supervised by Van Buren Township employees, when neither the parents or guardian can be contacted, I hereby give my consent for emergency medical treatment as shall be necessary under the circumstances by any physician licensed under the laws of the State of Michigan.

I understand that the Township may take photographs for the use in Township publications and news release without my written consent.

I have read the above waiver/release of liability and understand it.

 

Signature: (Parent or Guardian, if not over 18 years of age)              Date

 

Please Mail to : Van Buren Recreation Department, 46425 Tyler Road, Van Buren Twp, MI 48111