Participant Registration And Release Form - Dcr Universal Access Progra printable pdf download

DCR UNIVERSAL ACCESS PROGRAM

2016 PARTICIPANT REGISTRATION & RELEASE FORM

General Information:

OFFICE: __V__P__D__PCA__GS __W __DB _________IN____

GN_______________________________________________NEW

Please complete one form for each adult participant. Children may be registered along with an adult family member on

the same form. You must be a parent or legal guardian to register children under 18 years old. Please print clearly.

Name(s):_____________________________________________________________________________

Address _____________________________________________________________________________

City________________________________ State_________________ Zip_______________________

Phone______________________________ Email*__________________________________________

Would you prefer to receive a twice yearly newsletter of activities via ____e-mail or _____mail?

Optional: Veteran Status: __yes I have served in the U.S. military __no I am not a veteran

The undersigned, on behalf of the below mentioned participant, in connection with his/her participation in

events held by DCR’s Universal Access Program hereby release the Commonwealth of Massachusetts,

Department of Conservation and Recreation, and its employees, permittees, vendors, agents, representatives,

volunteers and other governmental entities working for or with DCR (“Providers”) from any and all liability,

loss, damages, costs, claims and/or causes of action, including but not limited to property damage and emotional

and bodily injuries, including death, arising in any way from my or my child’s or ward’s enrollment or

participation in any program, course or recreational activity of every type and description provided or sponsored

by the Providers. I understand that my or my child’s or ward’s participation in such program, course or

recreational activity may involve risk and the possibility of injury to myself or to my child or ward, and to

others, and of property damage. I hereby release and hold the Providers harmless from liability for any such

injury or damage, whether incurred by me, my minor child or my ward, and including any injury that may occur

as a result of emergency care provided by the Providers. I also hereby indemnify the Providers from any

liability, loss, damages, costs, claims and/or causes of action brought by the minor child, the ward, or members

of the minor child’s or ward’s family arising from their enrollment or participation, and from claims of others

who I or my child or ward injure while participating in such program, course or recreational activity, including

any injury that may occur as a result of emergency care provided to others by the Providers.

The undersigned, on behalf of the below mentioned participant, in connection with his/her participation in

events held by DCR’s Universal Access Program, gives my permission for the Commonwealth of

Massachusetts, including it DCR, to use photographs and/or videotape of me or the participant for publicity and

media purposes, including but not limited to internet publications and inclusion in any DCR publication.

_____________________________________________

________________________

Individual Participant:

SIGN HERE

DATE

If participant is under 18 years of age or has legal guardian, signature of parent/guardian required:

_____________________________________________

Parent/Guardian:

SIGN HERE

Parent/Legal Guardian name (please print): ___________________________

Participant Registration And Release Form - Dcr Universal Access Progra