Oak Island Parks and Recreation Department
YOUTH REGISTRATION FORM
(Please Print*) Name: ______________________________ (Please circle) Male Female
Date of Birth:___________________________________ AGE: ___________ T shirt size: _____
Parent/Guardian: _______________________________________________________________
Address (Physical): ______________________________________________________________________
Address (Mailing): ______________________________________________________________________
Home Phone # : _________________________________ Work #: _______________________
Emergency contact: _____________________Phone #: ________________ Phone #: ________
Emergency contact: _____________________Phone #: ________________ Phone #: ________
Medical information staff should be aware of, including allergies:
Are there any foods or drinks that your child cannot consume?
Insurance information/Medical Carrier:
I, parent/guardian of the above named participant in the following activity,_______________________, hereby give approval for his/her participation in any and all activities during the duration of the program/league/sport. I assume all risks and hazards incidental to participation including transportation to and from activities; and hereby waive, release, absolve, indemnify and agree to hold harmless the Town of Oak Island, local league organization, the Oak Island Parks and Recreation Department, sponsors, supervisors, officials, participants and all other persons involved in various capacities with the above activity for any claims, demands, or courses of action arising out of or by reason of the above activity for which the participant is registered. I also give my permission for the free and unrestricted use of my name and picture in any broadcast or written account of the event/activity.
I also grant permission to managing personnel or other league representatives to authorize and obtain medical care from any licensed physician, hospital or medical clinic should the participant become ill or injured while participating in said activity or any associated activities at times when neither parent/guardian is available to grant authorization for emergency treatment.
I also agree to return equipment/uniforms or any other supplies issued to the participant in good condition.
*Parents will be required to disclose transportation methods for campers arriving to and departing from camp.
Parents will be asked to provide names of persons who will be allowed to transport campers.
*If a parent/guardian is habitually late picking up their child, then additional fees will be assessed.
Parent/Guardian Signature:
_____________________________________________________________