CC Youth Waiver Form

Town Of Waterford


                          Participation/Waiver Form


I, ___________________, give my son/daughter ________________ permission to
use the Waterford Community Center (WCC). I understand that the WCC is not
responsible for the time or manner in which my child arrives or leaves the
Community Center. I further understand that the WCC and the WCC staff are
not responsible for personal injury or loss of property. I also understand
that my child is expected to follow the WCC Rules and Regulations and
he/she may be suspended or expelled from use of the WCC at any time.  In
the event my child is suspected and/or proven to have been involved with
any destruction or vandalism of property, my family and I will take full
responsibility for the reimbursement to make the necessary repairs.

In consideration of being allowed to use the WCC, the undersigned
acknowledges and agrees to hereby release and hold harmless the Town Of
Waterford, the WCC and its employees with respect to any and all injury,
disability, or death incurred while visiting the WCC. I certify that my
child is in good physical condition and fully able to participate in
activities at the WCC. In the event your efforts to contact me are
unsuccessful, I ________________, parent/legal guardian of ________________
consent to emergency evaluation and/or treatment of my child while visiting
the WCC.

Signed: ______________________________       Date: _____________

Printed Name: _________________________



Child Information:

Name: ____________________________          Age: _____        Date of
Birth: ______

Address: ______________________________________


Contact Name: _________________________________    Relation to child:
_________

Phone Number: __________


Allergies/Medications: _____________________________________


Emergency Contact: _____________________________   Phone: _________________