Choose one of these buttons for quick access to your choice of information about leagues, or classes.
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Choose one of these buttons for quick access to your choice of information about leagues, or classes.
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Bluffton Family Recreation Contact and Medical Release Form Name: ____________________________ Phone: ______________________ Birth date: ___/_____/_____ T-shirt Size YS YM YL AS AM AL Address: __________________________________________________________ City: __________________ State: ________ Zip: ____________ Emergency Contacts : Parent Name: _____________________________ Daytime Phone: ______________________ Parent Name: _____________________________ Daytime Phone: ______________________ Other Name: _____________________________ Daytime Phone: ______________________ Relationship: __________________ Physician: ______________________________ Phone: ______________________ Please list anyone besides your emergency contacts who may pick up your child. Name: ______________________________ Phone: __________________ Name: ______________________________ Phone: __________________
Please list any medical concerns, such as allergies, medications, and/or medical history that your child may have. ______________________________________________________________________________ _______________________________________________________________________________________ Waiver and Release of all Claims Please read this form carefully. When you sign this form you waive and release all claims for injuries your child might sustain arising out of their use of the facilities and participation in the activities and programs at Bluffton Family Recreation center. (BFR) Acknowledge risk injury: As a participant in the activities or programs at BFR, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries, including death, damages or loss which my child may sustain as a result of participation or use of such facilities, activities or programs. Waive, Release & Indemnify: I hereby waive, release and discharge any and all claims I may have or may acquire against BFR, its officers, agents, servants and employees as a result of my or my child's participation in the fitness center, activities and programs of BFR; and I agree to indemnify and hold harmless BFR, its officers, agents, servants and employees from any and all claims resulting from injuries, damages, and losses, including death, sustained while I or my child are in the fitness center or using BFR facilities, except for willful and wanton misconduct by BFR or its authorized personnel. I have read and fully understand the above Waiver and Release of all Claims Form. ___________________________________ ` Print Name of Participant _____________________________________________________ __________ Signature of Parent/Legal Guardian Date Signature below authorizes BFR to transport your child to field trips and secure emergency medical transportation for your child. This form does not authorize or guarantee treatment upon arrival at the designated source of emergency medical or dental treatment, as each emergency facility sets their own treatment procedures. Please sign below if you grant BFR permission to transport your child for field trips and emergency care. _______________________________________ _____________ Parent's Signature Date |
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