Fillable Registration Form printable pdf download

Henrico County Division of Recreation and Parks - Registration Form

Participant Name (First & Last)

Program #

Location

Age

Date of Birth

M/F

Program Title

Fee

Parent/Legal Guardian: _________________________________________________________________________________

Date of Birth: __________________

M / F

Henrico resident? Y / N

Address: ___________________________________________ City: ____________________ State: _____ Zip: __________

Primary Phone: _____________________________________ Secondary Phone: __________________________________

Email:_______________________________________________________________________________________________

Emergency Contact Name: (Spouse, Relative, Friend) ___________________________________________________________

Relationship: ________________________ Primary Phone: ___________________ Secondary Phone: __________________

Special Accommodations & Medication: If the participant requires one (or both) of the following, you must check the box(es)

and call Therapeutic Recreation at 501-5135. See website for forms and additional information.

 Special accommodations due to a disability. /  Medication(s) needed during program hours.

At Your Leisure:  Please e-mail me a copy of the guide

 Please mail me a copy of the guide

Photographs: If you do not want pictures of you or your child taken, please initial here. ____________

These photos are for publicity or departmental use.

REQUIRED SIGNATURE

Assumption of Liability:

I understand that this program may involve strenuous physical activity and that risk of physical injury is inherent in this recre-

ational activity. In consideration for participating in this program and recreational activity, I agree to assume the full risk of any injuries, including death, dam-

age, or loss. I further understand that Henrico County, its officers, agents, and employees are not liable for any injuries that may result from the negligence of

persons conducting this recreational program. I understand that this agreement constitutes an assumption of risk and release for any injury, including death,

damages, or loss. The terms hereof shall serve as a release and assumption of risk for my heirs, executors and administrators. Henrico County recommends

that participants secure adequate medical insurance to cover any injuries that may arise from their activities. I have read this agreement and agree to the

conditions stated above. If participant is under 18 years of age, parent or legal guardian must sign this release.

Signature of Each Participant or Parent/Legal Guardian of Each Minor Participant Required

Date

Signature of Each Participant or Parent/Legal Guardian of Each Minor Participant Required

Date

PAYMENT INFORMATION

Payer Name: ____________________________________________________________________________________  M /  F

Address: __________________________________________ City: ______________________ State: _____ Zip: _____________

Primary Phone: ________________________________________ Secondary Phone: ____________________________________

Method of Payment: Payable to County of Henrico

Total Fees: $ __________________

 Cash (Walk-in registration only.)

 Debit Card (Pin-based only. Walk-in registration only.)

 Credit Card (American Express, Discover, MasterCard, and Visa are accepted. Walk-in or online only.)

 Check/Money Order #_________ (Registration forms sent by mail must be paid by check or money order.)

Mailing Address: Program Registration, Henrico Recreation and Parks, PO Box 90775, Henrico VA 23273-0775

Registration Form

Related Articles

Related forms

Related Categories