2022-2023 FALL, WINTER SPRING

STERLING RECREATION DEPARTMENT REGISTRATION FORM 2022 - 2023 * REGISTER ONLINE at STERLINGREC.COM* Separate forms needed for Sterling Rec Basketball, Wachusett Mountain Programs/Passes, Pakachoag Music PLEASE PRINT CLEARLY Participant ’ s Name: ____________________________________________________________

Mailing Address:______________________________________________________________________

Home Phone:____________________ Work/Cell Phone: ___________________________

E - Mail:_____________________________________________________

Complete if under 18: Birth Date:_________

Age_________ Grade _________ Gender __________

Parent(s) Name: _____________________________________________________

Emergency Contact - other than parent:

Name: ________________________________________________

Phone Number: _________________________________________

Please list any physical limitations/restrictions and/or medications being taken: ________________________________

Waiver In consideration of this application, I or my child hereby release, discharge and/or indemnify the Recreation Director, Recreation Committee, Staff, and/or Volunteers, the Town of Sterling and its ’ elected officials of any liability related to the operation of this program. I hereby give my consent for emergency medical care prescribed by a licensed Doctor of Medicine or Doctor of Dentistry. It is possible that pictures will be taken during classes. I agree that pictures taken during program hours could potentially be used for promotional purpose. I understand that all participants of the Recreation programs will be respectful of anyone employed by or contracted by the Recreation Department when participating in Recreation sponsored programs. I understand that the Recreation Department will not be responsible for any or all personal items brought to any Recreation Dept. sponsored programs. I understand when I or a designated person signs my child out from a Recreation sponsored program, the responsibility of my child and his/her belongings are my sole responsibility

Signature _______________________________________ Date______________ Signature of participant (or parent/guardian if under 18) WAIVER MUST BE SIGNED TO PARTICIPATE IN PROGRAMS

One week before start of program COST additional $10.00

PROGRAM TITLE

DATE/SESSION

TIME

COST

Checks payable to TOWN OF STERLING Mail forms to Sterling Recreation, 1 Park St., Sterling, Ma 01564 or drop off in the bill pay box at the Butterick Municipal Building

For office use only : Date ________

Amount________

Check #________

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