PROGRAM OR ACTIVITY:
_____________________________________ FEE:_______________CK _____ CASH __
PARTICIPANT REGISTRATION AND INFORMATION: (please print)
NAME:_________________________________________________ NICKNAME:_____________________ M ___ F ___
ADDRESS: _____________________________________________________ TELEPHONE: ______________________
DATE OF BIRTH:__________ AGE:_____ GRADE:_____ SCHOOL: SMS/CMS/EHS_____OTHER________________
PARENT/GUARDIAN:_______________________________WORK PHONE:_____________CELL:________
OTHER PARENT:____________________________HOME PHONE:_____________WORK:__________CELL:________
If you want to receive recreation notices on upcoming events, please give us your e-mail address:______________________
MEDICAL HISTORY:
Family Physician:____________________________Phone:_________________ Insurance Carrier:_____________________
Does this child have any medical conditions, allergies (food, insects, environmental or other), heart conditions, disabilities,
present or past injuries, fears, diabetes, bleeding disorders, seizure disorders, respiratory illness, or any other significant
medical condition which may affect their participation in the above stated program? Yes_______ No _______.
If yes, please explain:
Allergies:___________________ Asthma:________ Physical Limitations:________________________________
Other (Please explain)_________________________________________________________________________________
Emergency Medication: Epi-Pen__ Inhaler__ Antihistamine __Insulin___ Does child carry this with him/her:___________
(Parent or adult emergency contact will be responsible for administering above named emergency medication.)
List any regular prescription and non-prescription medications:________________________________________________
Does Child wear Glasses? Yes ____ No____ Contact Lenses? Yes ____ No ____ Date of Last Tetanus: _______
EMERGENCY
TREATMENT AUTHORIZATION:
I/we the undersigned parents (s) or guardian (s) of _______________________________, hereby authorize that in case
of emergency and in my absence, the administrators, staff or volunteers associated with this program, to act as my agent
and seek emergency medical or dental treatment at any hospital, dental or emergency care center. If there is an emergency
and I cannot be reached at the above listed address/phone numbers, please contact:
EMERGENCY CONTACT:__________________________PHONE:_____________RELATIONSHIP:________________
who is authorized to act in my/our behalf.
ACKNOWLEGEMENT,
DISCLOSURE, AND SIGNATURE:
I/we the undersigned parent (s)/guardian (s) of the above named child, give said son/daughter permission to participate in the above stated program. I/we agree not to hold the Town of Stratham, its Recreation Commission, Selectmen, Program Committee or its Administrators, Staff, Counselors, Coaches, Chaperones or any other volunteers and/or agents associated with the program in any capacity liable or responsible in any way for personal injuries or property damage that might occur during or as the result of said child’s participation in the program.
I/we have read, understand and agree to the above terms and conditions of this registration, and have fully disclosed all pertinent information relative to my child's participation.
Signature: ____________________________________________________________ Date:_______________________