Last Name: Adult First Name:
Home Phone: Work Phone:
Address:
City: State: Zip:
Email Address:
Resident Status: If you are a resident of Rocky Hill, you must file a yearly* "Proof of Residence."Check One: Already on file Enclosed* Swim lessons require new "Proof of Residence" each time.
When registering for Summerscape or Fall Soccer, please list child's Grade for next fall. * If your are registering for Youth Football/Cheerleading, you must also complete and submit the Conference Application & Medical Form * If your are registering for Summerscape, please refer to the Parent Camper Information Packet for all required forms.
Emergency Contact Information Name: Phone
Medical Information/Special Needs If program lasts longer than one hour, without parental supervision, you must complete the expanded medical form for each participant. Otherwise, please describe here any special circumstances program supervisors should be aware of (e.g. allergies, medications, etc.), or special accommodations you require in order to participate:
Liability Release Form I am aware of the nature of this activity and I hereby assume responsibility for myself and/or my child (above), and/or his or her representatives to participate. I will not hold the Town of Rocky Hill, the Department of Parks and Recreation, and/or its employees or agents responsible in case, of any accident or injury as a result of this participation. I hereby further agree to indemnify and save harmless the Town of Rocky Hill, a municipal corporation of the State of Connecticut, from and against any and all loss, damage, claim, demand, liability or expense by reason of any damage or injury to property or person which may be claimed to have arisen as a result of or in connection with participation in this Parks and Recreation activity..
Parent/Participant Signature Date
Payment Information - No registration will be completed or held without total payment and all information. Check Enclosed - Check #: All Checks must be made payable to: "Town of Rocky Hill" Credit Card - Check One: Visa Mastercard
CC#: Exp. Date:
Name on Card: Signature: If submitting this form online, the box below must be checked or the registration will not be processed: This checkbox will serve as my signature for this registration.
Return this completed form to: Rocky Hill Parks & Recreation, 761 Old Main St, Rocky Hill, CT 06067 or fax to: 860-258-7666