PROGRAM REGISTRATION FORM 
Name of Participant____________________ Parent_________________
Address:_____________________________________________
City- State-Zip: ______________________________________
Email: ______________________________________________
Home #-_____________Office# _____________Cell# _______________
______________________________________________________________
Emergency Contact Name & Phone (other than yourself)
Child Registration __________ YES, I would like to coach!!
check here
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program name |
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Adult Registration
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Program name |
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______total fee
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Please state any medical problems that you and/or your child has
I give myself and/or my child (ren) permission to participate in the above listed program and to be treated by emergency personnel if needed. I further state that I assume responsibility in the inherent risks and hereby release and agree to hold the Buxton Recreation Department and its representatives, employees, instructors or facilities blameless in the event of injury without limitation, whether consisting of personal injury or property damage of any extent. Regarding field trips, I agree to provide return transportation in the vent of a medical emergency or for other reasons deemed necessary by the program director. Regarding photography, I give the Department permission to take photos of my children, for the purpose of promoting the Department and its activities. Regarding fitness programs, it is
advisable to consult your physician before beginning any exercise program.
_________________________________________________________________________________________________________________________________________________
Signature of participant or parent/guardian date
Please return this form and payment to;
Buxton Recreation Department, 185 Portland Road, Buxton, ME 04093
Please make checks payable to The Town of Buxton Recreation Department
call 929-8381 for questions or suggestions
2010 SOCCER REGISTRATION FORM
Name of Participant____________________ Parent_________________
Address: ______________________________________________
City- State-Zip: _________________________________________
Email: _________________________________________________
Home #- ____________ Office#___________Cell#______________
Emergency Contact Name & Phone (other than yourself)
If you coach your child will play for free! All coaches must submit a volunteer form & be screened.
__________ YES, I would like to coach!!
fees: register before Jun 4 $40.00 before July 2 $45.00
before Aug. 6 $50 between Aug. 7-Sept. 1 $55
WE WILL NOT ACCEPT REGISTRATIONS AFTER 9/1. WE NEED TIME TO ORDER SHIRTS &
OTHER EQUIPMENT & STAFF APPROPRIATELY.
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grade entering |
school attending |
fee |
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_________________________________________________________
Please state any medical problems that you and/or your child has
I give myself and/or my child (ren) permission to participate in the above listed program and to be treated by emergency personnel if needed.
I further state that I assume responsibility in the inherent risks and hereby release and agree to hold the Buxton Recreation Department and
its representatives, employees, instructors or facilities blameless in the event of injury without limitation, whether consisting of personal
injury or property damage of any extent. Regarding field trips, I agree to provide return transportation in the vent of a medical emergency
or for other reasons deemed necessary by the program director. Regarding photography, I give the Department permission to take photos of
my children, for the purpose of promoting the Department and its activities. Regarding fitness programs, it is advisable to consult your physician
before beginning any
exercise program. ________________________________________________________________________
Signature of participant or parent/guardian date
Please return this form and payment to;
Buxton Recreation Department, 185 Portland Road, Buxton, ME 04093
Please make checks payable to The Town of Buxton Recreation Department
call 929-8381 for questions or suggestions.
2010 Summer Registration Form
Summer registration for _________________________________________________________
2nd child ______________________________ 3rd child ________________________________
1st child 2nd child 3rdchild fees
___ session 1 June 28 $100 $90 $80 ______
___ session 2 July 6 (no camp Mon. 5th) $100 $90 $80 ______
___ session 3 July 12 $100 $90 $80 ______
___ session 4 July 19 $100 $90 $80 ______
___ session 5 July 26 $100 $90 $80 ______
___ session 6 August 2 $100 $90 $80 ______
___ session 7 August 9 $100 $90 $80 ______
___ all 7 sessions $525 $472.50 $420 ______
Above program is held from 8:30am until 3:30pm.
Before care (7:30-8:30 am) $100 for 7 weeks or $20.00 per week ______
After care (3:30-5:30pm) $200 for 7 weeks or $35.00 per week ______
$250 for both before & aftercare TOTAL FEE PD _______
Fees include all activity/entry fees and 1 t-shirt per child. All fees must be paid in full before camp starts.
t-shirt size ______________ adult or child
Please send a note to camp or with another adult if a parent is not picking up the child from camp. They must have a photo id with them. Please let us know if there is someone who should not be picking up your child.
We expect campers…. to have fun, to be treated fairly & respected, to respect others, to keep hands & feet to self, help & encourage others, keep voice at a reasonable level, cooperate even if doing something you do not want to do, ask for help when you have a problem, clean up after yourself, bring healthy snack & drinks, follow the rules & make new friends & have a blast!
The undersigned hereby expressly release & holds harmless the Town of Buxton, Rec Dept and its agents and employees from & against any and all claims, suits, actions and damages arising out of and connected with or resulting from my child(ren) participation in camp and before & aftercare. Parents need to be aware some activities involve the potential for injury. I/ we acknowledge that even with the best supervision injuries can be severe to result in disability or death. We have read this warning and shall assume responsibility for expenses and travel if an injury should occur. In case of an emergency every effort shall be made to reach the contact people listed. I give permission for my child to be treated by a licensed physician if necessary.
Parent/Guardian signature ___________________________________ date _______________
Parent/Guardian signature ____________________________________ date _______________
Insurance Carrier ______________________ Name on Policy ___________________________
Policy number ______________________________________
MEDICAL/REGISTRATIONS FORM
Participants name _______________________ age _______ DOB ________
grade completed ________________ School _______________________________
Parent __________________________ home phone ________________________
work phone _________________________ cell phone ______________________
address __________________________________________________________
In case of emergency who may we contact?
name ___________________________________ number _________________________
name ___________________________________ number _________________________
Is the participant on medication? ______________ reason __________________________
side effects ___________________________ dosage ___________ time _____________
start/end date to be administrated _____________________________________________
doctors name ______________ phone _____________________ I understand employees are not trained medical personnel. I give consent for
medication to be dispensed as stated above.
parent signature ________________________________________________________
allergies ______________________________________________________________
does the participant have physical or emotional restrictions or disabilities, please list: ______________________________________
________________________________
other information we should be aware of: ________________________________________
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