Military Family Waiver Verification Form - Parks & Recreation Department City Of Neenah
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1CITY OF NEENAH
PARKS & RECREATION DEPARTMENT
MILITARY FAMILY WAIVER
VERIFICATION FORM
{CITY OF NEENAH RESIDENTS ONLY}
(Please Print)
Name of Deployed Resident:
first
last
Address:
Neenah, WI
54956
Branch of Service:
Deployment to:
Date of Deployment:
Return Date:
Verified by:
Date:
PROGRAMS REQUESTING: {Please complete the below form.}
(Please Print)
LAST
FIRST
GUARDIAN’S
NAME
NAME
STREET
CITY
NEENAH
ZIP
54956
PHONE (H)
(W) / (C)
(EMERGENCY)
EMAIL
RESIDENCY (Check one):
City of Neenah
Non-Resident
SPECIAL CONSIDERATIONS
(Medications, disabilities, etc.): Name________________
PARTICIPANT’S FIRST NAME
M/F
BIRTH
AGE
GRADE
CLASS #
ACTIVITY
FEE
(Last name if different than above)
DATE
FALL
TO BE
2011
WAIVED
-
-
-
-
-
-
-
-
-
LIABILITY INFORMATION: You should be aware that Parks & Recreation programs involve an element of risk or danger for all participants
TOTAL FEES
and may cause serious injury, death, or property loss. The Neenah Parks & Recreation Dept. does not provide nor cover any medical or
WAIVED
hospital insurance for participants in our programs. All persons participating in NPRD sponsored activities must provide their own insurance
and assume risk of all injuries
.
ADULT SIGNATURE
DATE
I have read & understand the liability information listed above.
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