Town of Gorham, ME - Registration Form

Return to: Gorham Recreation Department 75 South Street, Suite One Gorham, ME 04038 Phone: 222-1630 Fax: 839-7752 Please do not use this form for our multi-week Summer Camps
Name	sex	date of birth	school	grade	program name	cost




We accept Master Card and Visa Card#_____________________________________________ Exp_______ 3 digit code ________ Signature __________________________________________					Total Due: Enclosed: Balance	_______ ________ ______

Parent Name ______________________________

Email ____________________________________ Phone_________________________

Address_______________________________________________________________

Parent Wk Phone _____________ Cell ____________

Emergency Contact ______________________________________________________ Phone ___________________

Are you available to coach? ______ Assist? ______

Please list any physical or behavioral limitations/restrictions,

medications being taken, and any side effects that they may have:

_______________________________________________________________________________________________

The undersigned hereby expressly releases and holds harmless the Town of Gorham, Gorham Recreation Department

and its agents and employees from and against any and all claims, suits, actions and damages arising out of, connected with, or resulting from my child’s participation in the above Gorham Recreation Department programs.

Further, I understand that there are inherent risks and dangers in participating in these programs and

I accept the responsibility to provide accident insurance for my child including ambulance transportation if necessary.

I understand the Gorham Recreation Department may take pictures and/or videos of the program

participants that may appear in future promotional materials.

_________________________________________________ _____________________________

Signature of Parent/Guardian Date