Ukulele Registration | City of Enterprise Recreation

Participant Information

Participant Name *

First

Last

Sex *

Male
Female

List All Medical Problems/Conditions or Limitations Participant Has

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Parent/Guardian Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Phone Number *

Parent/Guardian Email *

Primary Emergency Contact

Primary Emergency Contact (other than Parent/Guardian) *

First

Last

Primary Emergency Contact Phone Number *

Insurance Carrier / Policy Number

Consent for Medical Treatment

As a parent or legal guardian of the above name registrant(s), I hereby give my consent for emergency medical care prescribed by a fully licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions deemed necessary to preserve the life, limb or well-being of the registrant(s). By signing below I authorize transportation by ambulance by EMS personnel.

I have read and understand the Medical Treatment Form

Parent/Guardian Signature or Participant 18+ (Medical Treatment Form Signature) *

Clear Signature

Date *

Liability Release Form

This agreement releases The City of Enterprise, Enterprise High School, Enterprise Elementary and Instructors from all liability relating to injuries that may occur during activity on location. I fully understand that participating in these youth sports/activities presents the risk of serious injury or death. In my capacity as parent or legal guardian, I understand the risks and my responsibility to notify the other parent or legal guardians as the minor of the risk involved with any participation and hold harmless, release, indemnify and defend the City of Enterprise, its representatives, employees, agents and insurers (hereinafter "City of Enterprise") I have made a conscious decision to allow the named minor to be involved in these activities. I agree that my health and accident insurance will be the primary insurance to cover expenses for any such injury, including rehabilitation. Registration fees will be non-refundable unless of Dr. Release or Recreation Director decision.

By signing below I forfeit all right to bring a suit against The City of Enterprise, Enterprise High School, Enterprise Elementary and instructors for any reason. I will make every effort to obey safety precautions as listed in writing and as explained to me verbally. I will ask for clarification when needed.

I understand that by signing this agreement I waive certain legal rights and that it is binding up men, my heirs, and legal representatives. I have been given time to consider whether to sign this release and to review it with my own counsel and have either done so or voluntarily elected not to do so. I have voluntarily signed my name showing that I accept the above provisions. I fully understand and agree to the above terms.

I have read and understand the Liability Release Form

Parent / Legal Guardian or Participant 18+ (Liability Release Form Signature) *

Clear Signature

Date *

Payment

Enterprise Ukulele Registration Fee ($30.00) *

30.00

Total *

$0.00

Returns *

I understand there will be a 3% fee on any returns

Credit Card *

Card Number

Security Code

Name on Card

Expiration/