Randolph Recreation Department Information Form

HOUSEHOLD INFORMATION: (please print all information legibly)

Todays Date: _________________
Household Last Name: _________________________
Resident: _____ Non Resident: ________
Household Email Address: (You may have more than one):_____________________________________________
__________________________________________________
PRIMARY HOUSEHOLD PERSON:

SECONDARY HOUSEHOLD PERSON:

Name_________________________________

Name_________________________________

Birthdate: ____________ Gender: _________

Birthdate: ____________ Gender: __________

Address: ______________________________

Address: ______________________________

City_____________ State_____ Zip_________

City_____________ State_____ Zip_________

Phone:

Phone:

Home: ___________________

Home: ___________________

Work: ___________________

Work: ___________________

Cell: ____________________

Cell: ____________________

EMERGENCY CONTACT: (Other than mentioned on this form)

Contact Name: _________________________________________ Relationship to household: _________________________
Phone: Home: ___________________

Work: ___________________ Cell: ______________________________________

FAMILY MEMBER INFORMATION: (children and/ or other people in household)

Name: ___________________________________

Gender ________ Birthdate ___________ Grade in Fall ___________

T-shirt size Youth: XS S M L Adult: XS S M L

Allergies ______________________________________________________
Medication or Medical Condition ___________________________________________________________________________
Name: ___________________________________

Gender ________ Birthdate ___________ Grade in Fall ___________

T-shirt size Youth: XS S M L Adult: XS S M L

Allergies ______________________________________________________
Medication or Medical Condition ___________________________________________________________________________
Name: ___________________________________

Gender ________ Birthdate ___________ Grade in Fall ___________

T-shirt size Youth: XS S M L Adult: XS S M L

Allergies ______________________________________________________
Medication or Medical Condition ___________________________________________________________________________

Waiver Agreement
Release of Liability: I authorize the staff and volunteers of the Randolph Recreation Department to provide basic first aid or to call
additional medical care in the event of an emergency, for the above listed individual. I understand the inherent risk in participating in this
program and hereby give my consent, for above listed participant, to participate in programs offered by the Town of Randolph Recreation
Department. I further agree to release the Town of Randolph and their staff and volunteers from any liability connected with the above listed
individual.
Consent: I hereby consent to and authorize the Town of Randolph Recreation Department the rights to publish, reproduce and use for
advertising or any other purpose any photograph, video image, audio recording and other likeness of individuals listed on this registration.

Parent/Guardian Signature: ___________________________________________________ Date: ___________________

OPTIONAL QUESTIONS:
1. Would you like to subscribe to the E-Rec Newsletter?
YES
NO
Email address to send it to: _____________________________________________________
2. Would you like information on Youth Scholarships?

YES

NO

Randolph Recreation Department, 7 Summer Street, PO Drawer B, Randolph, VT 05060

Phone (802) 728-5433 x 18 Fax (802) 728-5818 Email: rec@randolphvt.org

Find us at Randolphvt.org, Front Porch Forum and Facebook at Town of Randolph Recreation