WeaverParkForm

Uptown Playground at Weaver Park
For youth ages 5 - 12

* Indicates required field

Child 1 *

First

Last

Age *

Grade in Fall *

Sex *

School *

Child 2 *

First

Last

Age *

Grade in Fall *

Sex *

School *

Child 3 *

First

Last

Age *

Grade in Fall *

Sex *

School *

Child 4 *

First

Last

Age *

Grade in Fall *

Sex *

School *

Please choose week attending. If more than 1 week but less than All, please note which weeks in the Special Requests/Other Information space. *

Special Requests/Other Information *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Contact *

Relationship *

Phone Number *

Email *

Secondary Contact *

Relationship *

Phone Number *

Email *

Consent for Participation

I the parent/ guardian of the registrant, a minor, agree that the registrant and I will abide by the rules/ guidelines of the HCC it’s affiliated organizations and sponsors. Recognize the possibility of physical injury associated with the Uptown Playground at Weaver Park program and in consideration for the HCC, accepting the registrant for its programs and activities. I hereby release, discharge and or otherwise indemnify the HCC, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of facilities utilized for the program against any claims by or on behalf of the registrant as a result of the registrant’s participation in the program and or being transported to or from the same, which transportation I here-by authorize. Further permission must be granted by the HCC for the registrant without insurance coverage to participate.

Signature / Name *

Consent for Minor Medical Treatment

As a parent or legal guardian of the above participant, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry . This care may be given under whatever conditions are necessary to preserve the health and safety of the participant.

Signature / Name *

Date *

Medical Insurance *

Doctors Name *

Phone *

(Participation will not be denied based on whether or not participant is insured)

Photo/Video Consent

I/We grant permission for my child to have his/her photo/video taken and published on the HCC Programs public internet site or any other type of media.

Photo/Video Consent *

Please note our refund policy available on our website at https://www.huntcommunitycenter.org/programs.html

Submit

Uptown Playground at Weaver Park​For youth ages 5 - 12

Consent for Participation

Consent for Minor Medical Treatment

Photo/Video Consent

Uptown Playground at Weaver Park
For youth ages 5 - 12