Stay & Play Registration Form

* Indicates required field

Child's Name *

First

Last

Age *

Gender *

Male Female

Home Phone *

Parent/Guardian Name *

First

Last

Parent/Guardian Name *

First

Last

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell Phone *

Email *

Emergency Contact *

First

Last

Emergency Contact Phone Number *

Please Indicate any allergies, medical conditions, or physical limitations *

Please provide a list of 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 agree to all terms of this statement

Your Name *

First

Last

Submit