Program Registration Form - Bedford County, Virginia printable pdf download

Bedford County

Parks & Recreation Department

Program Registration Form

Participant Name: _____________________________________________

Customer #:________

Date of Birth: ___________

M or F

Age: _____

Bedford County/City Resident: Yes or No

Address: ____________________________________

City: __________________

State: _____

Email Address: _____________________________________________________

Phone: ________________

Parent/Guardian Name: ______________________________________________________

Date of Birth: ___________

Relationship: ___________________

Phone: ________________

Emergency Contact Information

Name: __________________________

Relationship: ___________________

Phone: ________________

Any Medical Conditions, ETC

If you require any accommodation in order to participate, please explain prior to start of program.

______________________________________________________________________________________________

Program Title or Number

Start & End Date

Days

Time

Program Fee

______________________________________________________________________________________________

Amount Due: ________________

Apply in Person or Mail to:

1257 County Farm Road

(Checks payable to Bedford County Parks and Recreation)

Bedford, VA 24523

How did you hear about Bedford County Parks and Recreation programs:

Please check one of the following?

Newspaper: ___

Website: ___

Program Guide: ___

Flyer: ___

Email: ___

Other: ___________________

Parks and Recreation Program Assistance Fund:

Yes, I would like to contribute _____$1.00, _____$5.00 ______$10.00 or other $___________ to the Parks and Recreation

scholarship fund. This fund allows children from the Bedford County/City area to attend recreational programs in our County

who financially may not be able to participate. We are grateful for your contribution and thank you for your donation!

WAIVER

In participating in Parks and Recreation Programs, sponsored by Bedford County, I hereby acknowledge that I understand that there are risks

of accidents resulting in bodily harm to me arising out of those activities. I understand that Recreation activities are planned with the safety of the participants

in mind. I further acknowledge that I have the physical capacity reasonably necessary to engage in the Recreation activity for which I have enrolled. In case

of emergency, accident or illness, I give my permission to be treated by a professional medical person and admitted to a hospital if necessary. I agree to be

the party responsible for all medical expenses which are incurred in my behalf. It is understood and agreed that the County, it’s Board, employees, volunteers

and agents shall be held harmless against all claims, damages, loss or expenses including attorney’s fees arising out of or resulting from my participation in

recreation programs. I also hereby waive ownership of any photographic record take by Bedford County or photographers contracted by Bedford County and

agree to permit Bedford County to use my image and/or my child’s image for and in Bedford County publications, posters, website, or other media, and agree

not to make any claim against Bedford County.

** I have read the above waiver and understand the contents**

___________________________________________________________________________

____________________________

SIGNATURE (PARENT OR GUARDIAN IF UNDER 18)

DATE

______________________________________________________________________________________________

For Office Use Only

Cash: _______

Check #: ______

Amount Paid: _______

Received By: ____________________