Greater Loch Raven 	Recreation Council Registration Form

This Registration Form shall be completed by the participant, or if the participant is a minor child, by the legal authorized parent or guardian of each minor/child participant.

Participant’s Name:	Date of Birth: _	/	_/	_ Male: _     Female:     _

Street Address:	Home Phone:	Cell Phone:  	

City/State:	_ Zip Code:	E-Mail:  	

Activity registering for:	Yes, I am interested in helping:	I would like more information:  	

Emergency/Health Information:

In case of an emergency, please notify (if minor/child participant, provide parent’s information or Guardian, as applicable)

Name:	Relationship:	Home Phone:	_	Cell Phone: 	

Name:	Relationship:	Home Phone:	Cell Phone: 	

Physician’s Name:	Physician’s Phone:  	

Name of Medical Provider:	Date of last tetanus immunization:  	

1.	Are there any medical or health factors or conditions that might affect participant’s performance in activity?  Yes:	No:  	

2.	Is participant taking any medications or have a condition that may affect participant’s safety or performance in the activity?   Yes:	No:  	

3.	Is participant required any special accommodations (due to disability) to participate in the activity:  Yes:	No:  	
If yes, please explain:  	

In case of injury or emergency, I for myself and/or participant (if participant is minor/child), and my personal representatives, heirs and assigns, (severally and collectively “I”) for this registration form) give permission for an activity representative to call 911 and transport participant to a hospital. I shall inform the Recreation Council, in writing, of any medical or health conditions of participant that occurs or develops and which could affect participant’s safety, performance or participation in or throughout the activity.

Signature of participant, or if minor, of parent/guardian:	Date:  	

Acknowledgment, Waiver and Release of Liability:
I hereby confirm participant is in good health and able to participate in the activity. Also, I have been advised to consult with a licensed physician prior to participation in the activity. I acknowledge the activity may involve both apparent and inherent risks and dangers of bodily injury or death and damage to property. I fully accept and acknowledge the activities may involve risks, and I hereby assume all dangers and risks associated with the participant in the activity and will be responsible for the same. I further understand that concussion information is available at www.cdc.gov/concussion.

I acknowledge that Baltimore County, Maryland, the Recreation Council, and their respective employees, directors, officers, volunteers, members and any other participant, entity, party or person involved in any regard with the Activity or the Activity premises and their respective agents, personal representatives, heirs, employees, contractors, successors and assigns (each an activity representative and collectively the “activity representatives”), shall not be responsible or liable in any regard or manner for any and all property damage or bodily injury (including serious physical injury or even death) incurred by participant or any party related thereto, as a result of his/her participation in the activity.

I have read, fully understand, and hereby freely sign, approve of, and agree to the terms of this Registration Form. I hereby expressly and forever unconditionally release, discharge, covenant not to sue, waive my rights and remedies, and agree to hold harmless and indemnify the activity representatives from any and all claims, costs, demands, losses, damages, or expenses, and from all acts of active or passive negligence or other fault on the part of the activity representatives associated with, in whole or in part, participant’s involvement with the activity. I shall inform the Recreation Council in writing if any information provided in this Registration Form is incorrect or changes through the course of the activity. I shall present a government issued photo identification card including, but not limited to, my driver’s license, passport, or United States Visa to the activity representative for review, if requested, at the time I submit this Registration Form to the recreation council.

Signature of Participant (if over 18) OR of parent/guardian (if under 18):  	

Date:	_

Print Name of Signature:	Relationship to Participant:  	

Print Name of minor child, if applicable:  	

9/2015