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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