HALF DAY LETS PLAY REGISTRATION

Half Day, Let's Play!

* Indicates required field

Child's Name *

First

Last

Age *

Grade *

Parent Name *

First

Last

Home Phone *

Cell Phone *

Work Phone *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact *

First

Last

Emergency contact phone *

Please indicate any allergies or medical conditions we should know about: *

Please list authorized people to check-out your child *

Participation in this program may involve risk of injury. As a parent, guardian or participant, I am aware of these hazards and my ability to participate. In consideration for participation in the program listed above, I hereby for myself, my heirs, executors and administrators waive and release all rights against the Gilford Youth Center, the Gilford Community Church, its officers, employees, agents, volunteers, and supervisors, except in the case of their sole negligence, from all losses, injury, damages, fees, and other expenses, arising out of or in connection with participation in the program and activities. In addition, I give my permission for the child to be treated by qualified medical personnel in the event that the above named parent/guardian cannot be reached at the phone numbers provided. As a parent, guardian or participant, I allow the Gilford Youth Center to take my child’s picture/video for advertising and promotional purposes. *

I, as a legal parent/guardian, agree to the terms listed above.

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