EmailMe Form - EAGLE RECREATION PARTICIPANT REGISTRATION

PARTICIPANT'S PERSONAL INFORMATION

Name *

First Last

Date of Birth *

MM / DD / YYYY

Age *

Gender (M/F) *

Address + City, State, Zip *

Phone: *

### - ### - ####

School *

Grade: *

PARENT & LEGAL GUARDIAN INFORMATION (18 years or younger)

Parent/Guardians Name #1 *

Cell Phone: *

### - ### - ####

Email Address: *

Parent/Guardians Name #2 *

Cell Phone: *

### - ### - ####

Email Address: *

Home Phone

### - ### - ####

Other

### - ### - ####

EMERGENCY CONTACT & PICKUP INFORMATION

Contact Name *

Cell Phone: *

### - ### - ####

Ralationship *

Email Address: *

Parent/Guardians Name #2 *

Cell Phone: *

### - ### - ####

Email Address: *

Home Phone

### - ### - ####

Other

### - ### - ####

PROGRAM SELECTION

*

Program Name
Session # (applicable)
Date
Time
Shirt Size (applicable)
Fee

Program Name
Session # (applicable)
Date
Time
Shirt Size (applicable)
Fee

Program Name
Session # (applicable)
Date
Time
Shirt Size (applicable)
Fee

Program Name
Session # (applicable)
Date
Time
Shirt Size (applicable)
Fee

Total Fee

$ Dollars . Cents

There are service fees for paying online.

https://www.govpaynow.com/gps/user

I, as the participant or parent/legal guardian of the above named child(ren), hereby give permission for my/his/her participation in the above listed activity(ies). I am aware of and understand that there may be potential risks involved with participation in any activity, and that the Town and/or Village of Eagle do not provide accident insurance and cannot assume any responsibility for injury to any participants in its recreation programs. I agree to hold harmless the Town and/or Village of Eagle and its officers, employees, and volunteers from any and all claims.

Signature *
Clear

Date *
MM / DD / YYYY