Author: Recreation Aide

HOMESCHOOL REGISTRATION FORM
Open Registrations Throughout The Program
Late Registration ends October 31

CCPR OFFERS SPORTS TO PARTICIPANTS BETWEEN 3 AND 17 YEARS OLD. PLEASE MAKE SURE YOUR CHILD’S AGE IS WITHIN THIS RANGE BEFORE REGISTERING. PLEASE USE SEPARATE FORMS FOR EACH CHILD.

Registration for session:
$10.00/
Participant

Participants Name: _________________________________________ Birth date: ______/_____/_______ Age: (now) _______
Please List any medical problems or allergies (specify which child):
_______________________________________________________________________________________________________________________
Does this participant have a sibling( s) signing up? YES NO (circle one)
Name of sibling: __________________________________________________________________ Birth Date: ___________________
Name of sibling: __________________________________________________________________ Birth Date: ___________________
Name of sibling: __________________________________________________________________ Birth Date: ___________________
Name of sibling: __________________________________________________________________ Birth Date: ___________________
Name of sibling: __________________________________________________________________ Birth Date: ___________________

1st Parent /Guardian	Home Phone	Mobile Phone	Work Phone
Email Address
2nd Parent / Guardian
Email Address
Emergency Contact

I give CCPR my permission to take photographs and/or record video and/or audio or otherwise record images and likenesses of my child to use for CCPR promotional and or/marketing materials. I further consent that my child's name and identity may be revealed therein or by descriptive text or commentary. Please fill out liability form on back

Yes No (Check one)
Parent / Guardian Signature: ________________________________________________ Date:__________________
__________________________________________________________Date:__________________

Receipt number: _____________________ League: ______________________ In Database: ________________________
Check #: ____________________

CASWELL COUNTY

Preserving the Past, Embracing the Future

Parks and Recreation Department

P.O. Box 98 Yanceyville, NC 27379

Phone (336) 694-4449 FAX (336) 694-5855

Release and Indemnity Agreement
I understand that participating in the recreational program(s) selected involves risk of injury. These risks include inclement weather, accidents while traveling, equipment problems or failures, contact with and actions of other participants, slips/trips/falls, and musculoskeletal injuries, among others. I choose for myself or for my child to participate in the selected program(s) despite the risks. By signing this form, I acknowledge all risks of injury, illness, and death and affirm that I have assumed all responsibility of injury, illness, or death in any way connected with participation in the program(s). I also agree for myself and for any child participant to follow all rules and procedures of the program and to follow the reasonable instructions of the teachers and supervisors of the program. In return for the opportunity to participate in this program, I agree for myself and for my heirs, assigns, executors, and administrators to release, waive, and discharge any legal rights I may have to seek payment or relief of any kind from the County, its employees or its agents for injury, illness, or death resulting from this program. If I am registering a child for a program, I agree that I am a parent, legal guardian, or am otherwise responsible for the child whose application I am submitting and that I release, waive, and discharge any legal rights that I may assert on behalf of the child participating in the program(s). I also agree not to sue the County, its employees, or its agents and agree to indemnify the County for all claims, damages, losses, or expenses, including attorneys fees, if a suit is filed concerning an injury, illness, or death to me or to my child resulting from participation in the program(s).I understand that the County of Caswell provides no insurance coverage for me. I have read this document thoroughly and understand that by signing this form I am waiving legal rights.

Name of Participant:	Date:
Signature of Parent/Legal Contact:	Printed Name of Parent/Legal Guardian:

Mailing Address of 1st Parent / Guardian:	City	State	Zip code
Mailing Address of 2nd Parent / Guardian:	City	State	Zip code

Revised 8/29/2019